Provider Demographics
NPI:1619221934
Name:STEWARD, JUSTIN (ACNP)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:STEWARD
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 847176
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7176
Mailing Address - Country:US
Mailing Address - Phone:903-237-1800
Mailing Address - Fax:903-237-1810
Practice Address - Street 1:2901 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5128
Practice Address - Country:US
Practice Address - Phone:903-758-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-08
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX740497363LA2100X
MI4704405482363LA2100X
TXAP122586363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX329656803Medicaid
TX325317YKS4Medicare PIN