Provider Demographics
NPI:1073709622
Name:LEWIS, JEREMIAH P (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:P
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12289 HANCOCK ST
Practice Address - Street 2:STE 34
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5801
Practice Address - Country:US
Practice Address - Phone:317-815-8950
Practice Address - Fax:317-815-8951
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000791A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400056232Medicare PIN
INP01118037Medicare PIN
INM400055363Medicare PIN