Provider Demographics
NPI:1043201056
Name:LEWIS, DIANA LOUISE (NP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LOUISE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:LOUISE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:NM HIGHWAY 120 @MILE MARKER 12.5, SOUTH SIDE OF HIGHWAY
Mailing Address - Street 2:P.O. BOX 203
Mailing Address - City:OCATE
Mailing Address - State:NM
Mailing Address - Zip Code:87734
Mailing Address - Country:US
Mailing Address - Phone:505-666-2475
Mailing Address - Fax:
Practice Address - Street 1:NM STATE HIGHWAY 120,
Practice Address - Street 2:MILE MARKER 12.5
Practice Address - City:OCATE
Practice Address - State:NM
Practice Address - Zip Code:87734
Practice Address - Country:US
Practice Address - Phone:505-666-2475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR24775363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM400019OtherINDIVIDUAL PTAN
NMNMB2163OtherGROUP PTAN NMB2163
NM22002570Medicaid
NM41903765Medicaid
NMQ60378Medicare UPIN