Healthcare Provider Details

I. General information

NPI: 1609859313
Provider Name (Legal Business Name): SIDNEY WILSON LAVENDER II PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 08/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

PO BOX 344
WINSTON SALEM NC
27102-0344
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2255
  • Fax: 336-716-3348
Mailing address:
  • Phone: 336-716-2255
  • Fax: 336-716-3348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number000100189
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: