Provider Demographics
NPI:1003857244
Name:LEWIS, LISA M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 OLDE TOWNE PKWY STE 250
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-4428
Mailing Address - Country:US
Mailing Address - Phone:770-971-3376
Mailing Address - Fax:770-578-8567
Practice Address - Street 1:4800 OLDE TOWNE PKWY STE 250
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4428
Practice Address - Country:US
Practice Address - Phone:770-971-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4105363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCFZVMedicare ID - Type Unspecified
GAQ27787Medicare UPIN