Basic Information
| Provider Information | |||||||||
| NPI: | 1528374147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYONS | ||||||||
| FirstName: | JENNINGS | ||||||||
| MiddleName: | DEWAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2511 DELANEY AVE | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106679417 | ||||||||
| FaxNumber: | 9108152882 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 RAVENSWOOD RD | ||||||||
| Address2: | |||||||||
| City: | HAMPSTEAD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284434022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103413300 | ||||||||
| FaxNumber: | 9108152882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2010 | ||||||||
| LastUpdateDate: | 10/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0010-02385 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0010-02385 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.