Provider Demographics
NPI:1457317281
Name:LEWIS, JOHN C (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 W CENTER RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-2700
Mailing Address - Country:US
Mailing Address - Phone:402-506-9124
Mailing Address - Fax:402-261-0240
Practice Address - Street 1:7100 W CENTER RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-2700
Practice Address - Country:US
Practice Address - Phone:402-506-9124
Practice Address - Fax:402-261-0240
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098995001OtherMEDICARE, PTAN
NE1002605900Medicaid