Provider Demographics
NPI:1518543727
Name:LEWIS, PHILIP (MS, RD, CSSD, CSCS)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MS, RD, CSSD, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12076 W MAKENNA LN
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-7790
Mailing Address - Country:US
Mailing Address - Phone:520-990-0024
Mailing Address - Fax:
Practice Address - Street 1:12076 W MAKENNA LN
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653-7790
Practice Address - Country:US
Practice Address - Phone:520-990-0024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR86045663133VN1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports DieteticsGroup - Single Specialty