Healthcare Provider Details

I. General information

NPI: 1730315748
Provider Name (Legal Business Name): BRAD L LEWIS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 KEYSTONE AVE
CRESSON PA
16630-1214
US

IV. Provider business mailing address

529 KEYSTONE AVE
CRESSON PA
16630-1330
US

V. Phone/Fax

Practice location:
  • Phone: 814-886-2911
  • Fax: 814-886-2911
Mailing address:
  • Phone: 814-935-7279
  • Fax: 814-886-5470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA003125L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: