Provider Demographics
NPI:1104846724
Name:LEWIS, SAMANTHA RAQUEL (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAQUEL
Last Name:LEWIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 HAZEL DR
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-2634
Mailing Address - Country:US
Mailing Address - Phone:607-624-4467
Mailing Address - Fax:
Practice Address - Street 1:1075 BROADWAY
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NY
Practice Address - Zip Code:10570
Practice Address - Country:US
Practice Address - Phone:914-773-6901
Practice Address - Fax:914-769-8505
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT145622163W00000X
NY517976-1163WG0000X
CT7304363L00000X
NY320051363LC1500X
NY401200363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health