Provider Demographics
NPI:1639402134
Name:LEWIS, HEATHER SUE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:SUE
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:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:ID
Mailing Address - Zip Code:83611-1330
Mailing Address - Country:US
Mailing Address - Phone:208-382-4285
Mailing Address - Fax:208-382-5081
Practice Address - Street 1:402 LAKE CASCADE PKWY
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:ID
Practice Address - Zip Code:83611-7702
Practice Address - Country:US
Practice Address - Phone:208-382-4285
Practice Address - Fax:208-382-5081
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-813363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808480300Medicaid
ID808480300Medicaid