Basic Information
| Provider Information | |||||||||
| NPI: | 1649840406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEAD | ||||||||
| FirstName: | LEWIS | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4B WOODVIEW DR | ||||||||
| Address2: | |||||||||
| City: | LEDYARD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063391676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609415944 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 SHAWS CV | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063204902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604478304 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2021 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 9749 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.