Provider Demographics
NPI:1467535138
Name:LEWIS, AMANDA G (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:G
Last Name:LEWIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 300 W
Mailing Address - Street 2:SUITE 401
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3344
Mailing Address - Country:US
Mailing Address - Phone:801-357-7499
Mailing Address - Fax:801-373-5980
Practice Address - Street 1:1055 N 300 W STE 401
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3306
Practice Address - Country:US
Practice Address - Phone:801-357-7499
Practice Address - Fax:801-373-5980
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4980126-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ43585Medicare UPIN
UT000065810Medicare PIN