Healthcare Provider Details

I. General information

NPI: 1861386476
Provider Name (Legal Business Name): LYDIA L. HARRIS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

1591 HIGHLAND VALLEY CIR
WILDWOOD MO
63005-4263
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6339
  • Fax: 314-251-4564
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2025032287
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: