Basic Information
| Provider Information | |||||||||
| NPI: | 1811359631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | PAMELA | ||||||||
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| Credential: | CSFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1903 CORNERSTONE LN # B | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740172037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188633182 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1202 N MUSKOGEE PL | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740173058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183412556 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2016 | ||||||||
| LastUpdateDate: | 03/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | 136634 | OK | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.