Provider Demographics
NPI:1366773400
Name:LEWIS, MICHAEL JEFF (CRNA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JEFF
Last Name:LEWIS
Suffix:
Gender:M
Credentials:CRNA
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 1350
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71058-1350
Mailing Address - Country:US
Mailing Address - Phone:318-617-5563
Mailing Address - Fax:
Practice Address - Street 1:905 CRESCENT RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-3908
Practice Address - Country:US
Practice Address - Phone:318-617-5563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LATAP002239367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered