Healthcare Provider Details

I. General information

NPI: 1164633715
Provider Name (Legal Business Name): STASHA S LEWIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3723 W 12600 S STE 150
RIVERTON UT
84065-7296
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-285-4561
  • Fax:
Mailing address:
  • Phone: 801-285-4561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM6258
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number51747
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10122609-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: