Provider Demographics
NPI:1316050727
Name:LENGYON, ETHELEEN OLIVIA (PA-C)
Entity type:Individual
Prefix:
First Name:ETHELEEN
Middle Name:OLIVIA
Last Name:LENGYON
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 1:1505 LBJ FWY STE 700
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-6065
Mailing Address - Country:US
Mailing Address - Phone:214-358-2300
Mailing Address - Fax:214-579-6941
Practice Address - Street 1:3604 LIVE OAK ST
Practice Address - Street 2:SUITE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6168
Practice Address - Country:US
Practice Address - Phone:214-358-2300
Practice Address - Fax:214-366-6330
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00047363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA00047OtherTX MEDICAL LICENSE
TXS95407Medicare UPIN