Basic Information
| Provider Information | |||||||||
| NPI: | 1992786768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | HASTING INDIAN MEDICAL CENTER | ||||||||
| Address2: | 100 S. BLISS | ||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184583120 | ||||||||
| FaxNumber: | 9184583279 | ||||||||
| Practice Location | |||||||||
| Address1: | HASTING INDIAN MEDICAL CENTER | ||||||||
| Address2: | 100 S. BLISS | ||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184583120 | ||||||||
| FaxNumber: | 9184583279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 06/29/2011 | ||||||||
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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 | 208000000X | 10026 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 10038540A | 05 | OK | MEDICAID | 150304001 | 05 | AR | MEDICAID |