Basic Information
| Provider Information | |||||||||
| NPI: | 1457984908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYDA | ||||||||
| FirstName: | BRITTANY | ||||||||
| MiddleName: | AUTUMN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367187224 | ||||||||
| FaxNumber: | 4149556211 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 SILAS CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367187224 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2020 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5157 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0010-11516 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1457984908 | 05 | WI | MEDICAID |