Provider Demographics
NPI:1194746222
Name:LYDSTON, MICHELLE M (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:LYDSTON
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 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:12800 BOTHELL EVERETT HWY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208
Practice Address - Country:US
Practice Address - Phone:425-316-5150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004803363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8472219Medicaid
WAG8877112Medicare PIN
WA8856156Medicare ID - Type Unspecified
WA8472219Medicaid
WAP75642Medicare UPIN
WAG8877111Medicare PIN