Provider Demographics
NPI:1194728139
Name:STEWART, SUSAN S (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:S
Last Name:STEWART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:J
Other - Last Name:SWEENEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:MAUI MEDICAL GROUP
Mailing Address - Street 2:2180 MAIN STREET
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793
Mailing Address - Country:US
Mailing Address - Phone:808-242-6464
Mailing Address - Fax:808-244-0603
Practice Address - Street 1:MAUI MEDICAL GROUP
Practice Address - Street 2:2180 MAIN STREET
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793
Practice Address - Country:US
Practice Address - Phone:808-242-6464
Practice Address - Fax:808-244-0603
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003587363AM0700X
HIAMD-974363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00211373DMedicaid
GA00211373DMedicaid
GA97BBGJWMedicare ID - Type Unspecified