MEDICARE: LYDIA KYMBERLIE SPARKS RAMOS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	54510	CA
2	363A00000X	Physician Assistant	0010-08993	NC
3	2084P0800X	Psychiatry Physician	54510	CA

General Provider Information

NPI Number	:	1033632112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA KYMBERLIE SPARKS RAMOS PA-C

Provider Business Mailing Address
First Line	:	300 S MAIN ST STE 212
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-4201
Country	:	US
Telephone Number	:	919-594-2775
Fax Number	:

Provider Business Practice Location Address
First Line	:	128 RALEIGH ST
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-9043
Country	:	US
Telephone Number	:	919-594-2775
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2017
Last Update Date	:	03/21/2025

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