Healthcare Provider Details

I. General information

NPI: 1164116034
Provider Name (Legal Business Name): CRYSTAL ROSE LEWIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 S ROYLE RD STE 120
RIDGEFIELD WA
98642-7759
US

IV. Provider business mailing address

536 S ROYLE RD STE 120
RIDGEFIELD WA
98642-7759
US

V. Phone/Fax

Practice location:
  • Phone: 360-487-1086
  • Fax:
Mailing address:
  • Phone: 360-487-1086
  • Fax: 360-487-1088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA70110831
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: