Basic Information
| Provider Information | |||||||||
| NPI: | 1295742922 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | LOIS | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 SOUTHFIELD DR | ||||||||
| Address2: | STE 1370 | ||||||||
| City: | PLAINFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461684300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178375570 | ||||||||
| FaxNumber: | 3178375580 | ||||||||
| Practice Location | |||||||||
| Address1: | 1906 BELLEVIEW AVE SE | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409817000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001-107441 | VA | N | Nursing Service Providers | Registered Nurse | 163W00000X | 28226418A | IN | N | Nursing Service Providers | Registered Nurse | 367500000X | 0024-166441 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | CRNA CERT 72222 | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 010139902 | 05 | VA | MEDICAID | 010140005 | 05 | VA | MEDICAID | 000001074719 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 010140102 | 05 | VA | MEDICAID | 010139937 | 05 | VA | MEDICAID | 010139961 | 05 | VA | MEDICAID |