Provider Demographics
NPI:1346328408
Name:LEWALLEN, JAMIE (PA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:LEWALLEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26659 PLEASANT PARK RD
Mailing Address - Street 2:
Mailing Address - City:CONIFER
Mailing Address - State:CO
Mailing Address - Zip Code:80433-7714
Mailing Address - Country:US
Mailing Address - Phone:303-647-5300
Mailing Address - Fax:
Practice Address - Street 1:26659 PLEASANT PARK RD
Practice Address - Street 2:
Practice Address - City:CONIFER
Practice Address - State:CO
Practice Address - Zip Code:80433-7714
Practice Address - Country:US
Practice Address - Phone:303-647-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1638363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CF2908Medicare PIN