Provider Demographics
NPI:1225763576
Name:LEWIS, ROSS
Entity Type:Individual
Prefix:
First Name:ROSS
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 1:26473 61ST RD
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32008-2427
Mailing Address - Country:US
Mailing Address - Phone:386-854-0792
Mailing Address - Fax:
Practice Address - Street 1:2501 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1785
Practice Address - Country:US
Practice Address - Phone:229-333-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA29793225200000X
GAPTA004367225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant