Healthcare Provider Details

I. General information

NPI: 1174271803
Provider Name (Legal Business Name): MICHAEL JAMES LEWIS FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304A E 4TH ST
ELDON MO
65026-1808
US

IV. Provider business mailing address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

V. Phone/Fax

Practice location:
  • Phone: 573-552-5700
  • Fax: 573-557-2401
Mailing address:
  • Phone: 573-348-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022007578
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: