Provider Demographics
NPI:1689657132
Name:OWEN-WYATT, LYDIA F (PA-C)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:F
Last Name:OWEN-WYATT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3310 LIVE OAK ST FL 3
Practice Address - Street 2:YOUTH & FAMILY CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6153
Practice Address - Country:US
Practice Address - Phone:214-266-1257
Practice Address - Fax:214-266-1258
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX060359902Medicaid
TX060359904Medicaid
TX060359907Medicaid
P00049546OtherRAILROAD MEDICARE
TX060359905Medicaid
TX060359906Medicaid
TX8N4424OtherBLUE CROSS BLUE SHIELD
TX060359903Medicaid
TX060359906Medicaid
TX8L12653Medicare PIN
TX060359904Medicaid