Provider Demographics
NPI:1235771239
Name:LEWIS, ADAM
Entity Type:Individual
Prefix:
First Name:ADAM
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 1:22 ASHBOROUGH LN
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-6100
Mailing Address - Country:US
Mailing Address - Phone:601-335-3113
Mailing Address - Fax:
Practice Address - Street 1:6051 U S HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7200
Practice Address - Country:US
Practice Address - Phone:601-288-2690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00597363A00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1111054882OtherU.S. ARMY