1093896342 NPI number — HOLLY LEWIS MD

Table of content: HOLLY LEWIS MD (NPI 1093896342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093896342 NPI number — HOLLY LEWIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
HOLLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1093896342
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5450 WESTERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80301-2709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-415-4157
Provider Business Mailing Address Fax Number:
303-776-3109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 KEN PRATT BLVD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LONGMONT
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80501-6567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-776-1532
Provider Business Practice Location Address Fax Number:
303-776-3109
Provider Enumeration Date:
10/17/2006

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: 207R00000X , with the licence number:  DR.0036981 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04005930 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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