Provider Demographics
NPI:1780888446
Name:LEWIS, SHANNON KIMBERLY (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KIMBERLY
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 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:9701 SW BARNES RD
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6772
Practice Address - Country:US
Practice Address - Phone:503-297-8018
Practice Address - Fax:503-292-6601
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95971207R00000X
ORMD153467207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1780888446Medicaid
OR500635251Medicaid
CA00A959710Medicaid
CAWA95971AMedicare PIN
WA1780888446Medicaid
CA00A959710Medicaid