Provider Demographics
NPI:1659993103
Name:LYDON, KELSEA (PA-C)
Entity type:Individual
Prefix:
First Name:KELSEA
Middle Name:
Last Name:LYDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9430 TURKEY LAKE RD STE 114
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8015
Mailing Address - Country:US
Mailing Address - Phone:407-354-1202
Mailing Address - Fax:407-351-8801
Practice Address - Street 1:9430 TURKEY LAKE RD STE 114
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8015
Practice Address - Country:US
Practice Address - Phone:407-354-1202
Practice Address - Fax:407-351-8801
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113335363AS0400X
363A00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant