Provider Demographics
NPI:1730315748
Name:LEWIS, BRAD L (PAC)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:CRESSON
Mailing Address - State:PA
Mailing Address - Zip Code:16630-1330
Mailing Address - Country:US
Mailing Address - Phone:814-935-7279
Mailing Address - Fax:814-886-5470
Practice Address - Street 1:225 KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:CRESSON
Practice Address - State:PA
Practice Address - Zip Code:16630-1214
Practice Address - Country:US
Practice Address - Phone:814-886-2911
Practice Address - Fax:814-886-2911
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003125L363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA160391Medicare PIN