Provider Demographics
NPI:1033475546
Name:LEWIS, BRENNA KATHRYN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENNA
Middle Name:KATHRYN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6095
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-6095
Mailing Address - Country:US
Mailing Address - Phone:541-706-5922
Mailing Address - Fax:541-706-6869
Practice Address - Street 1:2500 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6015
Practice Address - Country:US
Practice Address - Phone:541-706-6892
Practice Address - Fax:541-706-6813
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD171914208000000X
390200000X
WAMD60652527208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500655062Medicaid
WAP01691429OtherRR PTAN WVH
WAP01691429OtherRR PTAN WVH