Provider Demographics
NPI:1790456440
Name:LEWIS, MARK ERWIN (DNP, CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ERWIN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11923 HUNTERS RUN DR
Mailing Address - Street 2:
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-1959
Mailing Address - Country:US
Mailing Address - Phone:410-371-8688
Mailing Address - Fax:
Practice Address - Street 1:5401 OLD COURT RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5103
Practice Address - Country:US
Practice Address - Phone:410-521-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR208090367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered