Basic Information
| Provider Information | |||||||||
| NPI: | 1457741688 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | KYLE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3209 S 23RD ST | ||||||||
| Address2: | STE 340 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984051602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535032598 | ||||||||
| FaxNumber: | 2534040506 | ||||||||
| Practice Location | |||||||||
| Address1: | 11216 SUNRISE BLVD E | ||||||||
| Address2: | STE 3-207 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983748848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537703700 | ||||||||
| FaxNumber: | 2534357019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2015 | ||||||||
| LastUpdateDate: | 09/29/2015 | ||||||||
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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 | 363AM0700X | PA60520595 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 2042164 | 05 | WA | MEDICAID |