Provider Demographics
NPI:1770911620
Name:O'BANNON, LYDIA B (PA-C)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:B
Last Name:O'BANNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:E
Other - Last Name:BARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3001 EDWARDS MILL RD
Mailing Address - Street 2:#200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5243
Mailing Address - Country:US
Mailing Address - Phone:919-781-5600
Mailing Address - Fax:919-863-6821
Practice Address - Street 1:2170 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7026
Practice Address - Country:US
Practice Address - Phone:530-543-5554
Practice Address - Fax:530-541-3016
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant