Healthcare Provider Details

I. General information

NPI: 1689657132
Provider Name (Legal Business Name): LYDIA F. OWEN-WYATT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 09/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3310 LIVE OAK ST FL 3 YOUTH & FAMILY CENTER
DALLAS TX
75204-6153
US

IV. Provider business mailing address

PO BOX 660599
DALLAS TX
75266-0599
US

V. Phone/Fax

Practice location:
  • Phone: 214-266-1257
  • Fax: 214-266-1258
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00528
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: