Provider Demographics
NPI:1720678022
Name:STEWART, JARED ALEXANDER
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:ALEXANDER
Last Name:STEWART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26901
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-0901
Mailing Address - Country:US
Mailing Address - Phone:405-271-4351
Mailing Address - Fax:
Practice Address - Street 1:920 STANTON L YOUNG BLVD # WP1140
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5036
Practice Address - Country:US
Practice Address - Phone:405-271-4351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041418380367500000X
TX1028724367500000X
OK219907367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered