Basic Information
| Provider Information | |||||||||
| NPI: | 1770073447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | KYLE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLEENER | ||||||||
| OtherFirstName: | STEVEN | ||||||||
| OtherMiddleName: | KYLE | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1490 | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286071490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287370221 | ||||||||
| FaxNumber: | 8558653651 | ||||||||
| Practice Location | |||||||||
| Address1: | 448 CRANBERRY ST | ||||||||
| Address2: | |||||||||
| City: | NEWLAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286578800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287370221 | ||||||||
| FaxNumber: | 8558653651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2018 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-08056. | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.