1528374147 NPI number — MR. JENNINGS DEWAYNE LYONS PA-C

Table of content: MR. JENNINGS DEWAYNE LYONS PA-C (NPI 1528374147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528374147 NPI number — MR. JENNINGS DEWAYNE LYONS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYONS
Provider First Name:
JENNINGS
Provider Middle Name:
DEWAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528374147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2511 DELANEY AVE
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28403-6003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-667-9417
Provider Business Mailing Address Fax Number:
910-815-2882

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 RAVENSWOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMPSTEAD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28443-4022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-341-3300
Provider Business Practice Location Address Fax Number:
910-815-2882
Provider Enumeration Date:
08/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  0010-02385 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0010-02385 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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