Provider Demographics
NPI:1740255389
Name:LEWIS, NATHANIEL DAVID (PA-C)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:DAVID
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31523
Mailing Address - Country:US
Mailing Address - Phone:912-466-9279
Mailing Address - Fax:
Practice Address - Street 1:145 ROYAL DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31523-6278
Practice Address - Country:US
Practice Address - Phone:912-466-9279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003667363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP32023Medicare UPIN
GA97WCCJVMedicare ID - Type Unspecified