Provider Demographics
NPI:1831311562
Name:LEWIS, BRYAN DAVID
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:DAVID
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WENONAH WAY
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-2461
Mailing Address - Country:US
Mailing Address - Phone:919-321-2023
Mailing Address - Fax:
Practice Address - Street 1:1003 12TH ST
Practice Address - Street 2:
Practice Address - City:BUTNER
Practice Address - State:NC
Practice Address - Zip Code:27509-1626
Practice Address - Country:US
Practice Address - Phone:919-575-7643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104121363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant