Provider Demographics
NPI:1538438452
Name:WILSON, LEWIS CODY (AA CERTIFIED)
Entity type:Individual
Prefix:MR
First Name:LEWIS
Middle Name:CODY
Last Name:WILSON
Suffix:
Gender:M
Credentials:AA CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 945375
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-5375
Mailing Address - Country:US
Mailing Address - Phone:516-945-3000
Mailing Address - Fax:704-248-5537
Practice Address - Street 1:5353 REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6015
Practice Address - Country:US
Practice Address - Phone:516-945-3000
Practice Address - Fax:704-248-5537
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1487367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant