Provider Demographics
NPI:1265839690
Name:LEWIS, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
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 1:903 BURKE ST
Mailing Address - Street 2:
Mailing Address - City:FORT SCOTT
Mailing Address - State:KS
Mailing Address - Zip Code:66701-2411
Mailing Address - Country:US
Mailing Address - Phone:417-321-2845
Mailing Address - Fax:
Practice Address - Street 1:202 STATE ST
Practice Address - Street 2:STE A
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701-2031
Practice Address - Country:US
Practice Address - Phone:417-321-2845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS150273363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily