Provider Demographics
NPI:1770507600
Name:LEWIS, MATTHEW J (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:J
Last Name:LEWIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-3787
Mailing Address - Country:US
Mailing Address - Phone:218-878-7699
Mailing Address - Fax:
Practice Address - Street 1:512 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-3787
Practice Address - Country:US
Practice Address - Phone:218-878-7699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1161207367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN685325100Medicaid