Provider Demographics
NPI:1386214633
Name:LEWIS, BRANDON ANTONIO
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:ANTONIO
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 1:1930 NW FERRIS AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-5629
Mailing Address - Country:US
Mailing Address - Phone:580-713-5150
Mailing Address - Fax:833-279-4266
Practice Address - Street 1:1930 NW FERRIS AVE STE 4
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-5629
Practice Address - Country:US
Practice Address - Phone:580-730-0232
Practice Address - Fax:833-279-4266
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200949300AMedicaid