Individual
TRACEY LEE LEWIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
102 W KENWOOD AVE STE 100, DECATUR, IL 62526
(217) 872-3800
(217) 872-0849
Mailing address
102 W KENWOOD AVE STE 100, DECATUR, IL 62526-4379
(217) 872-3800
(217) 872-0849
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085005631
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
F400420323
MEDICARE PIN
IL
Enumeration date
10/20/2015
Last updated
10/22/2020
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