Provider Demographics
NPI:1306301197
Name:MCCOY-LEWIS, DARREN JAMAAL
Entity type:Individual
Prefix:
First Name:DARREN
Middle Name:JAMAAL
Last Name:MCCOY-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 1:3309 AQUARIUS BLVD APT A
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-2179
Mailing Address - Country:US
Mailing Address - Phone:503-476-5941
Mailing Address - Fax:
Practice Address - Street 1:900 SE BAKER ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6808
Practice Address - Country:US
Practice Address - Phone:503-883-2213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer