Healthcare Provider Details

I. General information

NPI: 1487100491
Provider Name (Legal Business Name): JONATHAN DOUGLAS LYDAY AGPCNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 SAMARITANS RIDGE RD
ELKIN NC
28621-2472
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-526-3005
  • Fax: 336-526-3011
Mailing address:
  • Phone: 336-526-3005
  • Fax: 336-526-3011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5009435
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN224686
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5009435
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: