Provider Demographics
NPI:1730241167
Name:LEWIS, NIKKI MICSHAWN (PA)
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:MICSHAWN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:16121 GROVES ST APT B
Mailing Address - Street 2:
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459-2516
Mailing Address - Country:US
Mailing Address - Phone:337-537-3686
Mailing Address - Fax:
Practice Address - Street 1:1585 3RD ST
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5102
Practice Address - Country:US
Practice Address - Phone:337-531-4126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical