Provider Demographics
NPI:1104088327
Name:LEWIS, TRAVIS J (PA-C)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:J
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 CLAIRTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15236-4567
Mailing Address - Country:US
Mailing Address - Phone:412-466-5004
Mailing Address - Fax:412-466-7131
Practice Address - Street 1:810 CLAIRTON BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15236-4567
Practice Address - Country:US
Practice Address - Phone:412-466-5004
Practice Address - Fax:412-466-7131
Is Sole Proprietor?:No
Enumeration Date:2008-06-29
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053415363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031676650001Medicaid
PA1031676650002Medicaid
PA1031676650003Medicaid