Provider Demographics
NPI:1548763428
Name:LEWIS, LOGAN (FNP)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PAGE ROAD N
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374
Mailing Address - Country:US
Mailing Address - Phone:910-295-9211
Mailing Address - Fax:
Practice Address - Street 1:205 PAGE ROAD N
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-2837
Practice Address - Country:US
Practice Address - Phone:910-295-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF01181161363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner