Provider Demographics
NPI:1134260136
Name:LEWIS, JEANNINE MARIE (RPA-C)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:MARIE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3882 BERGER AVE
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-5002
Mailing Address - Country:US
Mailing Address - Phone:516-317-7886
Mailing Address - Fax:212-932-4154
Practice Address - Street 1:5141 BROADWAY
Practice Address - Street 2:3FW
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1159
Practice Address - Country:US
Practice Address - Phone:212-932-4738
Practice Address - Fax:212-932-4154
Is Sole Proprietor?:No
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010735363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical