Healthcare Provider Details

I. General information

NPI: 1922385442
Provider Name (Legal Business Name): JAMES EDWARD LEWIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2011
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W MAIN ST
LAKE CITY IA
51449-1585
US

IV. Provider business mailing address

1301 15TH AVE W ADMINISTRATION
WILLISTON ND
58801-3821
US

V. Phone/Fax

Practice location:
  • Phone: 712-464-3171
  • Fax: 712-464-4251
Mailing address:
  • Phone: 701-774-7401
  • Fax: 701-774-7479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR37053
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD161761
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: