Provider Demographics
NPI:1760026074
Name:WATSON, LEWIS SR
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:
Last Name:WATSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 ELAM RD
Mailing Address - Street 2:
Mailing Address - City:PAMPLIN
Mailing Address - State:VA
Mailing Address - Zip Code:23958-3242
Mailing Address - Country:US
Mailing Address - Phone:434-574-2247
Mailing Address - Fax:434-574-2028
Practice Address - Street 1:281 ELAM RD
Practice Address - Street 2:
Practice Address - City:PAMPLIN
Practice Address - State:VA
Practice Address - Zip Code:23958-3242
Practice Address - Country:US
Practice Address - Phone:434-574-2247
Practice Address - Fax:434-574-2028
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT25036828172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver