Provider Demographics
NPI:1609367291
Name:LEWIS, DAVID (PTA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 RAINTREE DR
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-2839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:431 RAINTREE DR
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538
Practice Address - Country:US
Practice Address - Phone:512-618-9460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-20
Last Update Date:2018-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2098131225200000X
WI2769225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant