Healthcare Provider Details

I. General information

NPI: 1528374147
Provider Name (Legal Business Name): JENNINGS DEWAYNE LYONS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2010
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 RAVENSWOOD RD
HAMPSTEAD NC
28443-4022
US

IV. Provider business mailing address

2511 DELANEY AVE ATTN: CREDENTIALING
WILMINGTON NC
28403-6003
US

V. Phone/Fax

Practice location:
  • Phone: 910-341-3300
  • Fax: 910-815-2882
Mailing address:
  • Phone: 910-667-9417
  • Fax: 910-815-2882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-02385
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-02385
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: