Provider Demographics
NPI:1144224114
Name:LEWIS, MARY JANE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 JOE OWENS RD
Mailing Address - Street 2:
Mailing Address - City:FLEETWOOD
Mailing Address - State:NC
Mailing Address - Zip Code:28626-9663
Mailing Address - Country:US
Mailing Address - Phone:336-877-5799
Mailing Address - Fax:
Practice Address - Street 1:1370 W D ST
Practice Address - Street 2:
Practice Address - City:N WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3506
Practice Address - Country:US
Practice Address - Phone:336-651-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC172991367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051430Medicaid
NC2618138CMedicare UPIN