Provider Demographics
NPI:1033627351
Name:LEWIS, LINDA RICHARDS (PA-C)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:RICHARDS
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2957 S IDA CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4034
Mailing Address - Country:US
Mailing Address - Phone:801-722-8359
Mailing Address - Fax:801-585-9166
Practice Address - Street 1:30 N. 1900 E
Practice Address - Street 2:SOM 5R218
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0002
Practice Address - Country:US
Practice Address - Phone:801-581-7822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10531394-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10531394-1206OtherDIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING- ACTIVE LICENSE
UT10531394-8906OtherDIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING- ACTIVE PA-C AND PA-CS LICENSE