Provider Demographics
NPI:1356331946
Name:LEWIS, JANE P (PA)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:P
Last Name:LEWIS
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 1:5031 CARL ALBERT RD.
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501
Mailing Address - Country:US
Mailing Address - Phone:918-423-1272
Mailing Address - Fax:
Practice Address - Street 1:1558 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-7036
Practice Address - Country:US
Practice Address - Phone:918-426-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK679363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100226780AMedicaid
OK100226780AMedicaid
S74689Medicare UPIN