Provider Demographics
NPI:1801879341
Name:LEWIS, JERRY LANE (PA)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:LANE
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-6805
Mailing Address - Country:US
Mailing Address - Phone:209-383-1848
Mailing Address - Fax:209-383-1296
Practice Address - Street 1:9235 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PLANADA
Practice Address - State:CA
Practice Address - Zip Code:95365-8088
Practice Address - Country:US
Practice Address - Phone:209-382-0253
Practice Address - Fax:209-382-2110
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA11479363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAML0489826OtherDEA CERT
CAS56623Medicare UPIN
CAML0489826OtherDEA CERT