Provider Demographics
NPI:1295785947
Name:LYDE, MICHELLE RENEE (RPA-C)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:RENEE
Last Name:LYDE
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1903
Mailing Address - Country:US
Mailing Address - Phone:718-260-2962
Mailing Address - Fax:718-522-3186
Practice Address - Street 1:937 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-2347
Practice Address - Country:US
Practice Address - Phone:718-789-2452
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008555-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP72462Medicare UPIN
NY5F5031Medicare ID - Type Unspecified