Provider Demographics
NPI:1528374147
Name:LYONS, JENNINGS DEWAYNE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JENNINGS
Middle Name:DEWAYNE
Last Name:LYONS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2511 DELANEY AVE
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6003
Mailing Address - Country:US
Mailing Address - Phone:910-667-9417
Mailing Address - Fax:910-815-2882
Practice Address - Street 1:40 RAVENSWOOD RD
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-4022
Practice Address - Country:US
Practice Address - Phone:910-341-3300
Practice Address - Fax:910-815-2882
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-02385363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical