Provider Demographics
NPI:1508058009
Name:LEWIS, WENDELL R JR (PA-C)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:R
Last Name:LEWIS
Suffix:JR
Gender:M
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 1:1200 J D ANDERSON DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3494
Mailing Address - Country:US
Mailing Address - Phone:304-598-1200
Mailing Address - Fax:
Practice Address - Street 1:45 HUNT CLUB DR
Practice Address - Street 2:
Practice Address - City:RIDGELEY
Practice Address - State:WV
Practice Address - Zip Code:26753-7567
Practice Address - Country:US
Practice Address - Phone:304-726-4501
Practice Address - Fax:304-726-4051
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01323282N00000X, 363A00000X
MDC05465363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA053081OtherPENNSYLVANIA PA LICENSE
VA0110002558OtherLICENSE
WV01323OtherWEST VIRGINIA LICENSE