Provider Demographics
NPI:1992200729
Name:LEWIS, MELISSA (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 BOWIE ST APT 2405
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-0063
Mailing Address - Country:US
Mailing Address - Phone:217-412-2038
Mailing Address - Fax:
Practice Address - Street 1:1700 E PALM VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-4677
Practice Address - Country:US
Practice Address - Phone:512-255-9102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-25
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant