Healthcare Provider Details

I. General information

NPI: 1801997226
Provider Name (Legal Business Name): AMANDA L LEWIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CHICO CT
MONTE VISTA CO
81144-1065
US

IV. Provider business mailing address

310 COUNTY ROAD 14
DEL NORTE CO
81132-8719
US

V. Phone/Fax

Practice location:
  • Phone: 719-852-9400
  • Fax:
Mailing address:
  • Phone: 719-657-4102
  • Fax: 719-657-4106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4185
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2181
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: