Provider Demographics
NPI:1164633715
Name:LEWIS, STASHA S (MD)
Entity Type:Individual
Prefix:DR
First Name:STASHA
Middle Name:S
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 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-285-4561
Mailing Address - Fax:
Practice Address - Street 1:3723 W 12600 S STE 150
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7296
Practice Address - Country:US
Practice Address - Phone:801-285-4561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6258208000000X
MN51747208000000X
UT10122609-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J7966Medicare PIN
TX188301901Medicaid
TX8J7853Medicare PIN