Provider Demographics
NPI:1700192424
Name:LIDSTROM, CAROL LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:LYNN
Last Name:LIDSTROM
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 1:3139 S WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1220
Mailing Address - Country:US
Mailing Address - Phone:734-722-2722
Mailing Address - Fax:734-722-7006
Practice Address - Street 1:1 FORD PL
Practice Address - Street 2:SUITE 2E
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3450
Practice Address - Country:US
Practice Address - Phone:313-937-3049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002244363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical