Healthcare Provider Details

I. General information

NPI: 1568293868
Provider Name (Legal Business Name): JEFFREY LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

352 ENGLENOOK DR
DEBARY FL
32713-1803
US

IV. Provider business mailing address

5813 GRANDE LAGOON BLVD
PENSACOLA FL
32507-9072
US

V. Phone/Fax

Practice location:
  • Phone: 407-732-7266
  • Fax:
Mailing address:
  • Phone: 850-390-1697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9119740
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: