Provider Demographics
NPI:1649713595
Name:STEWART, JEREMIAH (FNP)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ROSALIND REDFERN GROVER PKWY
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-5846
Mailing Address - Country:US
Mailing Address - Phone:432-221-1111
Mailing Address - Fax:
Practice Address - Street 1:400 ROSALIND REDFERN GROVER PKWY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5846
Practice Address - Country:US
Practice Address - Phone:432-221-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-27
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132514363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX553519ZV0WOtherTX MEDICARE