Provider Demographics
NPI:1023079332
Name:LEWIS, ANGELA VICTORIA (PA)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:VICTORIA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:VICTORIA
Other - Last Name:BURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:10000 SE MAIN ST STE 60
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2474
Mailing Address - Country:US
Mailing Address - Phone:503-257-0959
Mailing Address - Fax:
Practice Address - Street 1:10000 SE MAIN ST STE 60
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216
Practice Address - Country:US
Practice Address - Phone:503-257-0959
Practice Address - Fax:503-257-3457
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003171363AM0700X
ORPA167469363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKL09M771Medicare PIN
MDQ54633Medicare UPIN