Healthcare Provider Details

I. General information

NPI: 1255879185
Provider Name (Legal Business Name): JOHNNIE ROGER LEWIS JR. FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2017
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 W CONGRESS ST
TUCSON AZ
85745-2819
US

IV. Provider business mailing address

839 W CONGRESS ST
TUCSON AZ
85745-2819
US

V. Phone/Fax

Practice location:
  • Phone: 520-670-3909
  • Fax: 520-309-2560
Mailing address:
  • Phone: 520-670-3909
  • Fax: 520-309-2560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN160482
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP9910
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: