Basic Information
| Provider Information | |||||||||
| NPI: | 1316253990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | ANDREA | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3122 E MERIDIAN PARK LOOP | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996547255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073579590 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17025 SNOWMOBILE LN | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995777044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076949553 | ||||||||
| FaxNumber: | 9076949585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2010 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 26350 | AK | N | Nursing Service Providers | Registered Nurse | 363L00000X | 156904 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | NURR26350 | 01 | AK | STATE OF ALASKA NURSING BOARD RN LICENSE | OTHER | 156904 | 01 | AK | STATE OF ALASKA NURSING BOARD ANP LICENSE | OTHER |