Healthcare Provider Details

I. General information

NPI: 1497328330
Provider Name (Legal Business Name): SOUTHWEST FOOT AND ANKLE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9343 E SHEA BLVD STE B-130
SCOTTSDALE AZ
85260-6802
US

IV. Provider business mailing address

4300 TALBOT RD S STE 102
RENTON WA
98055-6238
US

V. Phone/Fax

Practice location:
  • Phone: 425-277-3668
  • Fax: 425-277-0732
Mailing address:
  • Phone: 425-277-3668
  • Fax: 425-277-0732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. PETRINA C LEWIS
Title or Position: OWNER
Credential: DPM
Phone: 425-277-3668