Provider Demographics
NPI:1801452685
Name:LEWIS, KRAGEN DESHAWN (DPT)
Entity type:Individual
Prefix:
First Name:KRAGEN
Middle Name:DESHAWN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 WOOD HOLLOW DR APT 475
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3049
Mailing Address - Country:US
Mailing Address - Phone:318-471-2010
Mailing Address - Fax:
Practice Address - Street 1:181 W BUSINESS 190 STE 5
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-3672
Practice Address - Country:US
Practice Address - Phone:318-471-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1316214225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist