Individual
SIDNEY WILSON LAVENDER II
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
000100189
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5554
PARTNERS
NC
01
—
7008754
AETNA
—
01
—
94713
MEDCOST
NC
Enumeration date
11/28/2005
Last updated
08/20/2010
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