1043201056 NPI number — DIANA LOUISE LEWIS N.P.

Table of content: DIANA LOUISE LEWIS N.P. (NPI 1043201056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043201056 NPI number — DIANA LOUISE LEWIS N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
DIANA
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEWIS
Provider Other First Name:
DIANA
Provider Other Middle Name:
LOUISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
N.P.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1043201056
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
NM HIGHWAY 120 @MILE MARKER 12.5, SOUTH SIDE OF HIGHWAY
Provider Second Line Business Mailing Address:
P.O. BOX 203
Provider Business Mailing Address City Name:
OCATE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-666-2475
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NM STATE HIGHWAY 120,
Provider Second Line Business Practice Location Address:
MILE MARKER 12.5
Provider Business Practice Location Address City Name:
OCATE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-666-2475
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R24775 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NM400019 . This is a "INDIVIDUAL PTAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NMB2163 . This is a "GROUP PTAN NMB2163" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 22002570 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41903765 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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