Provider Demographics
NPI:1396070769
Name:LEWIS, MICHAEL SHANNON (NP-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SHANNON
Last Name:LEWIS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3583 ZINER CT
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-4815
Mailing Address - Country:US
Mailing Address - Phone:614-394-4969
Mailing Address - Fax:
Practice Address - Street 1:170 TAYLOR STATION RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-4441
Practice Address - Country:US
Practice Address - Phone:614-851-7551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-02
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA0909042363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0059811Medicaid
OH0059811Medicaid