Basic Information
| Provider Information | |||||||||
| NPI: | 1306288527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | BRUCE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3385 MAPLE TERRACE DR | ||||||||
| Address2: | |||||||||
| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300243705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702713472 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 DAWSON COMMONS CIR | ||||||||
| Address2: | SUITE 430 | ||||||||
| City: | DAWSONVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305346269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062687905 | ||||||||
| FaxNumber: | 7062658788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2013 | ||||||||
| LastUpdateDate: | 07/30/2013 | ||||||||
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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 | 225200000X | PTA003133 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.