Basic Information
| Provider Information | |||||||||
| NPI: | 1952690158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 NORTHSIDE FORSYTH DR | ||||||||
| Address2: | STE 250 | ||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300416012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706674337 | ||||||||
| FaxNumber: | 7706674338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 NORTHSIDE FORSYTH BLVD | ||||||||
| Address2: | STE 3500 | ||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702926500 | ||||||||
| FaxNumber: | 7702926535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2011 | ||||||||
| LastUpdateDate: | 03/08/2018 | ||||||||
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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 | 363A00000X | 6070 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 003143594G | 05 | GA | MEDICAID | 003143594H | 05 | GA | MEDICAID | 003143594I | 05 | GA | MEDICAID |