Basic Information
| Provider Information | |||||||||
| NPI: | 1760641476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYDDANE | ||||||||
| FirstName: | CLAY | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3311 E MURDOCK ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672083054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899185 | ||||||||
| FaxNumber: | 3166899909 | ||||||||
| Practice Location | |||||||||
| Address1: | 3311 E MURDOCK ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672083054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899185 | ||||||||
| FaxNumber: | 3166899909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2008 | ||||||||
| LastUpdateDate: | 09/19/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 04-35145 | KS | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 200740730A | 05 | KS | MEDICAID |