Provider Demographics
NPI:1467841213
Name:LEWIS, ANTWON
Entity Type:Individual
Prefix:
First Name:ANTWON
Middle Name:
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 1:2404 E 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33605-2810
Mailing Address - Country:US
Mailing Address - Phone:813-380-0680
Mailing Address - Fax:
Practice Address - Street 1:2404 E 17TH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-2810
Practice Address - Country:US
Practice Address - Phone:813-380-0680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver