Basic Information
| Provider Information | |||||||||
| NPI: | 1598297566 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIDE | ||||||||
| FirstName: | BRIANNA | ||||||||
| MiddleName: | LYNDELL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3315 WATT AVE | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958213600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164816800 | ||||||||
| FaxNumber: | 9164811881 | ||||||||
| Practice Location | |||||||||
| Address1: | 4150 V ST | ||||||||
| Address2: | #1200 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958171460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167345028 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2017 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A159573 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.