Provider Demographics
NPI:1992102586
Name:LEWIS, KATHERINE (PA-C)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:FITZMAYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:N24W24050 BRANDON OAKS DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-6429
Mailing Address - Country:US
Mailing Address - Phone:915-873-9641
Mailing Address - Fax:262-373-0148
Practice Address - Street 1:4111 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1029
Practice Address - Country:US
Practice Address - Phone:414-299-3872
Practice Address - Fax:414-455-1929
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3751-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA.0004076OtherCOLORADO MEDICAL LICENSE