Provider Demographics
NPI:1134110356
Name:LEWELLEN, PHILLIP E (PA)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:E
Last Name:LEWELLEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2011 MURPHY AVE
Mailing Address - Street 2:SUITE 408
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2023
Mailing Address - Country:US
Mailing Address - Phone:615-327-1515
Mailing Address - Fax:615-352-1428
Practice Address - Street 1:1995 E OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1147
Practice Address - Country:US
Practice Address - Phone:954-791-6146
Practice Address - Fax:954-337-2733
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN551363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3666998Medicaid
TN4071394OtherBCBS
TN3666998Medicaid
TN970024755Medicare PIN
S47556Medicare UPIN
TN4071394OtherBCBS