Provider Demographics
NPI:1942577051
Name:LEWIS, MICHAEL D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:LEWIS
Suffix:
Gender:M
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 1:447 OLD NEWPORT BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4257
Mailing Address - Country:US
Mailing Address - Phone:949-650-3350
Mailing Address - Fax:
Practice Address - Street 1:447 OLD NEWPORT BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4257
Practice Address - Country:US
Practice Address - Phone:949-650-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant