Basic Information
| Provider Information | |||||||||
| NPI: | 1871212035 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIVELY | ||||||||
| FirstName: | LYDIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51 | ||||||||
| Address2: | |||||||||
| City: | SANDY RIDGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166770051 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 132 ABIGAIL LN | ||||||||
| Address2: | |||||||||
| City: | PORT MATILDA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168707153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142727200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2022 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA063727 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.