Basic Information
| Provider Information | |||||||||
| NPI: | 1235771239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | ADAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 ASHBOROUGH LN | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394026100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013353113 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6051 U S HIGHWAY 49 | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012882690 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2019 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00597 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 171000000X | Y | Other Service Providers | Military Health Care Provider |
ID Information
| ID | Type | State | Issuer | Description | 1111054882 | 01 | U.S. ARMY | OTHER |