1972642700 NPI number — SANDEE K LEWIS NP

Table of content: SANDEE K LEWIS NP (NPI 1972642700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972642700 NPI number — SANDEE K LEWIS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
SANDEE
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972642700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 BLACKMORE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASPER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82609-3345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-233-6000
Provider Business Mailing Address Fax Number:
307-233-6089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1035 ROSE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERTON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82501-2291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-857-6685
Provider Business Practice Location Address Fax Number:
307-857-9927
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  15065.0882 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 124167200 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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