Provider Demographics
NPI:1952690158
Name:LEWIS, MICHAEL T (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:LEWIS
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 GRAND OAK LN
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-6793
Mailing Address - Country:US
Mailing Address - Phone:770-241-1357
Mailing Address - Fax:
Practice Address - Street 1:440 GRAND OAK LN
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-6793
Practice Address - Country:US
Practice Address - Phone:770-241-1357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003143594HMedicaid
GA003143594GMedicaid
GA003143594IMedicaid
GA003143594GMedicaid