Individual
SIDNEY WILSON LAVENDER II
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
MEDICAL CENTER BLVD, WINSTON SALEM, NC 27157-0001
(336) 716-2255
(336) 716-3348
Mailing address
PO BOX 344, WINSTON SALEM, NC 27102-0344
(336) 716-2255
(336) 716-3348
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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