Provider Demographics
NPI:1396163226
Name:REWIS, MICHAEL E (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:REWIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 NW 145TH DR
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-2029
Mailing Address - Country:US
Mailing Address - Phone:904-399-5550
Mailing Address - Fax:904-346-4334
Practice Address - Street 1:3599 UNIVERSITY S BLVD 300
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4245
Practice Address - Country:US
Practice Address - Phone:904-399-5550
Practice Address - Fax:904-346-4334
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-28
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107927363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9107927OtherFLORIDA LICENSE