Provider Demographics
NPI:1093899155
Name:LEWIS, JENNIFER HENRY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:HENRY
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:DIANE
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1309 CARTHAGE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330
Mailing Address - Country:US
Mailing Address - Phone:919-774-6262
Mailing Address - Fax:919-774-1952
Practice Address - Street 1:1309 CARTHAGE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330
Practice Address - Country:US
Practice Address - Phone:919-774-6262
Practice Address - Fax:919-774-1952
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103113363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2755160Medicare ID - Type Unspecified
P56795Medicare ID - Type Unspecified