Healthcare Provider Details

I. General information

NPI: 1477479574
Provider Name (Legal Business Name): CELESTE LEW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY
POCATELLO ID
83201-5175
US

IV. Provider business mailing address

1651 PETERSBURG DR
CHUBBUCK ID
83202-5271
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-1000
  • Fax: 208-239-1000
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number62364
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: