Provider Demographics
NPI:1275018962
Name:LEWIS, AMANDA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
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 1:80 SEYMOU STREET
Mailing Address - Street 2:HARTFORD HOSPITAL SURGERY DEPT
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06102-5037
Mailing Address - Country:US
Mailing Address - Phone:860-972-5022
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:HARTFORD HOSPITAL SURGERY DEPT
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-5037
Practice Address - Country:US
Practice Address - Phone:860-972-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004281363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical