Basic Information
| Provider Information | |||||||||
| NPI: | 1346222023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIERRA | ||||||||
| FirstName: | LEWIS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549354560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 145 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549353423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268492 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 04/09/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 26876 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 26876 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 13288 | 01 | WV | DEAN | OTHER | 930118899 | 01 | WI | RAILROAD MEDICARE | OTHER | 30649400 | 05 | WI | MEDICAID |