Basic Information
| Provider Information | |||||||||
| NPI: | 1689815110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | JERL | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E LIBERTY ST | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063306000 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 SAINT JOSEPH LANE | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407418345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063306000 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2009 | ||||||||
| LastUpdateDate: | 11/07/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R82527 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 3006450 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 177959001 | 05 | AR | MEDICAID | 7100103680 | 05 | KY | MEDICAID |