Provider Demographics
NPI:1982365946
Name:LEWIS, MIRANDA GAYLE (PA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:GAYLE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:GAYLE
Other - Last Name:SOMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2225 US HIGHWAY 41 N
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-2749
Mailing Address - Country:US
Mailing Address - Phone:229-391-4100
Mailing Address - Fax:
Practice Address - Street 1:2225 US HIGHWAY 41 N
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-2749
Practice Address - Country:US
Practice Address - Phone:229-391-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant