Provider Demographics
NPI:1871749770
Name:LEWIS, RAVEN R (PA-C)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:R
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:S
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1430 TULANE AVE
Mailing Address - Street 2:# 8632
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2632
Mailing Address - Country:US
Mailing Address - Phone:504-896-9233
Mailing Address - Fax:504-896-9861
Practice Address - Street 1:200 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5720
Practice Address - Country:US
Practice Address - Phone:504-832-4033
Practice Address - Fax:504-832-5140
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200197363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant