Provider Demographics
NPI:1104430776
Name:STEWART, SHANNON ELYSE (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELYSE
Last Name:STEWART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 SNOWMASS CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-6677
Mailing Address - Country:US
Mailing Address - Phone:636-293-2634
Mailing Address - Fax:
Practice Address - Street 1:9556 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-1313
Practice Address - Country:US
Practice Address - Phone:314-961-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020028541363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant