Provider Demographics
NPI:1720858426
Name:LEWIS, ENZO JORDAN
Entity Type:Individual
Prefix:
First Name:ENZO
Middle Name:JORDAN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 HICKORY MILLS RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9056
Mailing Address - Country:US
Mailing Address - Phone:304-881-1054
Mailing Address - Fax:
Practice Address - Street 1:1124 HICKORY MILLS RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9056
Practice Address - Country:US
Practice Address - Phone:304-881-1054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant