Provider Demographics
NPI:1215935457
Name:LEWIS, PETRINA CELESTE (DPM)
Entity type:Individual
Prefix:
First Name:PETRINA
Middle Name:CELESTE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 TALBOT RD S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6238
Mailing Address - Country:US
Mailing Address - Phone:425-277-3668
Mailing Address - Fax:425-277-0732
Practice Address - Street 1:9343 E SHEA BLVD # B-130
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6802
Practice Address - Country:US
Practice Address - Phone:425-277-3668
Practice Address - Fax:425-277-0732
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP000000595213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7110729Medicaid
WA156354OtherDEPT OF L&I
AZPOD000986OtherPODIATRY LICENSE
WA156354OtherDEPT OF L&I