Provider Demographics
NPI:1205995578
Name:LEWIS, BRUCE DONALD JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:DONALD
Last Name:LEWIS
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1005 STARBOARD CT
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-1340
Mailing Address - Country:US
Mailing Address - Phone:410-612-2178
Mailing Address - Fax:
Practice Address - Street 1:2719 PULASKI HWY
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:MD
Practice Address - Zip Code:21040-1315
Practice Address - Country:US
Practice Address - Phone:410-612-0374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002016363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical