Provider Demographics
NPI:1043040199
Name:LEWIS, BRYCE ALLAN
Entity type:Individual
Prefix:
First Name:BRYCE
Middle Name:ALLAN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500A KMBL
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84602-4704
Mailing Address - Country:US
Mailing Address - Phone:801-839-5288
Mailing Address - Fax:
Practice Address - Street 1:1113 MERRILL HALL
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602-8337
Practice Address - Country:US
Practice Address - Phone:801-839-5288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTUT011486901256390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program