Provider Demographics
NPI:1477659829
Name:LEWIS, ALYSE NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:ALYSE
Middle Name:NICOLE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALYSE
Other - Middle Name:
Other - Last Name:HARLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6404 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:QUINTON
Mailing Address - State:VA
Mailing Address - Zip Code:23141-1204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5801 BREMO RD
Practice Address - Street 2:RICHMOND EMERGENCY PHYSICIANS INC
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1907
Practice Address - Country:US
Practice Address - Phone:804-287-7066
Practice Address - Fax:804-673-9531
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002313363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110002313OtherVA STATE LICENSE