Healthcare Provider Details

I. General information

NPI: 1265469738
Provider Name (Legal Business Name): AUGUSTINE WARNER LEWIS III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7864 RICHMOND TAPPAHANNOCK HWY
AYLETT VA
23009-3056
US

IV. Provider business mailing address

7864 RICHMOND TAPPAHANNOCK HWY
AYLETT VA
23009-3056
US

V. Phone/Fax

Practice location:
  • Phone: 804-746-1677
  • Fax: 804-769-3170
Mailing address:
  • Phone: 804-746-1677
  • Fax: 804-769-3170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101019901
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: