Provider Demographics
NPI:1992001358
Name:LEWIS, MIKKAEL K (PA)
Entity Type:Individual
Prefix:MR
First Name:MIKKAEL
Middle Name:K
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 N PIEDRAS ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79920-5001
Mailing Address - Country:US
Mailing Address - Phone:915-569-1386
Mailing Address - Fax:915-569-4890
Practice Address - Street 1:5005 N PIEDRAS ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79920-5001
Practice Address - Country:US
Practice Address - Phone:915-569-1386
Practice Address - Fax:915-569-4890
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1095616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant