Provider Demographics
NPI:1881768059
Name:LEWIS, LUCIUS JR (CRNA)
Entity type:Individual
Prefix:
First Name:LUCIUS
Middle Name:
Last Name:LEWIS
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 THORNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-6226
Mailing Address - Country:US
Mailing Address - Phone:662-588-0277
Mailing Address - Fax:804-545-0652
Practice Address - Street 1:1970 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-7202
Practice Address - Country:US
Practice Address - Phone:662-624-3401
Practice Address - Fax:662-627-5440
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR868756367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04225557Medicaid