Provider Demographics
NPI:1235522293
Name:LEWIS, GARY (ATC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7506 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:BEALETON
Mailing Address - State:VA
Mailing Address - Zip Code:22712-5677
Mailing Address - Country:US
Mailing Address - Phone:906-458-9027
Mailing Address - Fax:
Practice Address - Street 1:21000 EDUCATION CT
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20148
Practice Address - Country:US
Practice Address - Phone:571-442-3631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer