Healthcare Provider Details

I. General information

NPI: 1205932944
Provider Name (Legal Business Name): PETER WALLACE LEWIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6294 STATE HIGHWAY 154
SESSER IL
62884-2163
US

IV. Provider business mailing address

PO BOX 155
CHRISTOPHER IL
62822-0155
US

V. Phone/Fax

Practice location:
  • Phone: 618-625-6979
  • Fax:
Mailing address:
  • Phone: 618-724-2401
  • Fax: 618-724-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA01533
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: