Provider Demographics
NPI:1104572478
Name:NASSAB, LYDIA ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:ELIZABETH
Last Name:NASSAB
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 1:2925 DEBARR RD STE 240
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2959
Mailing Address - Country:US
Mailing Address - Phone:907-339-4650
Mailing Address - Fax:907-339-4694
Practice Address - Street 1:2925 DEBARR RD STE 240
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2959
Practice Address - Country:US
Practice Address - Phone:907-339-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15445363A00000X, 363A00000X
AK221587363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant