Basic Information
| Provider Information | |||||||||
| NPI: | 1407834633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4280 PLEASANT RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970589653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412969614 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1700 E 19TH ST | ||||||||
| Address2: | MID COLUMBIA MEDICAL CENTER | ||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970589653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412961111 | ||||||||
| FaxNumber: | 5412967614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP30004725 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN0006617 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 08263900O | 01 | OR | BCBS | OTHER | 9025966 | 05 | WA | MEDICAID | 0035006 | 01 | WA | WA DEPT LABOR | OTHER | 071290 | 05 | OR | MEDICAID |