Provider Demographics
NPI:1013690288
Name:LEWIS, ETHAN TAYLOR (DNP)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:TAYLOR
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12921 CANTRELL RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-1713
Mailing Address - Country:US
Mailing Address - Phone:501-615-8296
Mailing Address - Fax:
Practice Address - Street 1:12921 CANTRELL RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-1713
Practice Address - Country:US
Practice Address - Phone:501-615-8296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1138854367500000X
ARR108058163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse