Basic Information
| Provider Information | |||||||||
| NPI: | 1134372386 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 E HAWAII AVE | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836866011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084633244 | ||||||||
| FaxNumber: | 2084633034 | ||||||||
| Practice Location | |||||||||
| Address1: | 6357 N. FOX RUN WAY | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089600966 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2008 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | M-11279 | ID | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | M-11279 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1134372386 | 05 | ID | MEDICAID |