Provider Demographics
NPI:1093316176
Name:LEWIS, GABRIEL
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 PRAIRIE MOSS DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-6736
Mailing Address - Country:US
Mailing Address - Phone:602-826-1395
Mailing Address - Fax:
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-294-2621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28262442A390200000X
IN131055367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program