Provider Demographics
NPI:1164725248
Name:LEWIS, STEPHANIE M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:M
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1929 MASON DIXON HWY
Mailing Address - Street 2:
Mailing Address - City:CORE
Mailing Address - State:WV
Mailing Address - Zip Code:26541
Mailing Address - Country:US
Mailing Address - Phone:304-879-5020
Mailing Address - Fax:304-879-4105
Practice Address - Street 1:1929 MASON DIXON HWY
Practice Address - Street 2:
Practice Address - City:MAIDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26541-8152
Practice Address - Country:US
Practice Address - Phone:304-879-5020
Practice Address - Fax:304-879-4105
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
WV01676363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD0177663OtherDPS
WVML2302266OtherDEA