Provider Demographics
NPI:1457741688
Name:LEWIS, KYLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3209 S 23RD ST
Mailing Address - Street 2:STE 340
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1602
Mailing Address - Country:US
Mailing Address - Phone:253-503-2598
Mailing Address - Fax:253-404-0506
Practice Address - Street 1:11216 SUNRISE BLVD E
Practice Address - Street 2:STE 3-207
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8848
Practice Address - Country:US
Practice Address - Phone:253-770-3700
Practice Address - Fax:253-435-7019
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPA60520595363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2042164Medicaid
WAG8937499Medicare PIN
WAG8937498Medicare PIN