Provider Demographics
NPI:1144595174
Name:POMAVILLE, LIDIA S (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LIDIA
Middle Name:S
Last Name:POMAVILLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LIDIA
Other - Middle Name:
Other - Last Name:SCHETTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:866-630-9882
Mailing Address - Fax:920-682-5810
Practice Address - Street 1:3253 S HARLEM AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3073
Practice Address - Country:US
Practice Address - Phone:262-898-4400
Practice Address - Fax:708-788-6884
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-004255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant