Basic Information
Provider Information | |||||||||
NPI: | 1770911620 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | O'BANNON | ||||||||
FirstName: | LYDIA | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BARRETT | ||||||||
OtherFirstName: | LYDIA | ||||||||
OtherMiddleName: | E | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3001 EDWARDS MILL RD | ||||||||
Address2: | #200 | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276125243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197815600 | ||||||||
FaxNumber: | 9198636821 | ||||||||
Practice Location | |||||||||
Address1: | 2170 SOUTH AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH LAKE TAHOE | ||||||||
State: | CA | ||||||||
PostalCode: | 961507026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5305435554 | ||||||||
FaxNumber: | 5305413016 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/30/2013 | ||||||||
LastUpdateDate: | 06/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X |   |   | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.