Provider Demographics
NPI:1407054364
Name:LEWIS, MARY ELLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
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 1:700 PENNLYN PL
Mailing Address - Street 2:
Mailing Address - City:OCEAN CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08226-4156
Mailing Address - Country:US
Mailing Address - Phone:609-814-0339
Mailing Address - Fax:
Practice Address - Street 1:801 BOARDWALK
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-7509
Practice Address - Country:US
Practice Address - Phone:609-343-4003
Practice Address - Fax:609-343-4006
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00032700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant