Provider Demographics
NPI:1750947099
Name:LEWIS, COLIN ANDREW
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:ANDREW
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 1:614 TACOMA AVE UPPR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14216-2409
Mailing Address - Country:US
Mailing Address - Phone:585-350-9319
Mailing Address - Fax:
Practice Address - Street 1:70 JEWETT PKWY
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2391
Practice Address - Country:US
Practice Address - Phone:716-533-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY21440Medicaid