Provider Demographics
NPI:1003059338
Name:GOLETTE-LEWIS, MONTIA LORENZ (PA-C)
Entity type:Individual
Prefix:MS
First Name:MONTIA
Middle Name:LORENZ
Last Name:GOLETTE-LEWIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MONTIA
Other - Middle Name:LORENZ
Other - Last Name:GOLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2209 DEFENSE HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2209 DEFENSE HWY
Practice Address - Street 2:SUITE C
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2403
Practice Address - Country:US
Practice Address - Phone:888-808-6483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant