Provider Demographics
NPI:1861639395
Name:LEWIS, AMANDA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1330
Mailing Address - Country:US
Mailing Address - Phone:405-329-4102
Mailing Address - Fax:405-364-3476
Practice Address - Street 1:500 E ROBINSON ST
Practice Address - Street 2:SUITE 2300
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6697
Practice Address - Country:US
Practice Address - Phone:405-329-4102
Practice Address - Fax:405-364-3476
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1804363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical