Basic Information
| Provider Information | |||||||||
| NPI: | 1912319781 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | CANDACE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1058 BEAR CREEK BLVD | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302281849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707070808 | ||||||||
| FaxNumber: | 7707071580 | ||||||||
| Practice Location | |||||||||
| Address1: | 3334 HIGHWAY 155 | ||||||||
| Address2: | |||||||||
| City: | LOCUST GROVE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302483513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703057929 | ||||||||
| FaxNumber: | 7703057969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2014 | ||||||||
| LastUpdateDate: | 05/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 7062 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 007062 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 003214384A | 05 | GA | MEDICAID |