Provider Demographics
NPI:1568429496
Name:LEWIS, PATRICIA A (FNP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:LEWIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:A
Other - Last Name:TIBALDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 258
Mailing Address - Street 2:
Mailing Address - City:DOLLAR BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49922-0258
Mailing Address - Country:US
Mailing Address - Phone:989-619-4266
Mailing Address - Fax:
Practice Address - Street 1:13924 WADAGA RD
Practice Address - Street 2:
Practice Address - City:BARAGA
Practice Address - State:MI
Practice Address - Zip Code:49908
Practice Address - Country:US
Practice Address - Phone:906-353-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704192304363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ06607Medicare UPIN
MIG27604057Medicare PIN