Healthcare Provider Details

I. General information

NPI: 1578048518
Provider Name (Legal Business Name): STEPHEN MARTIN LEWIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 PEACHTREE RD NW
ATLANTA GA
30309-1281
US

IV. Provider business mailing address

55 WHITCHER ST NE STE 130
MARIETTA GA
30060-1156
US

V. Phone/Fax

Practice location:
  • Phone: 404-352-1409
  • Fax:
Mailing address:
  • Phone: 770-428-0462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8971
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: