Provider Demographics
NPI:1487100491
Name:LYDAY, JONATHAN DOUGLAS (AGPCNP)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DOUGLAS
Last Name:LYDAY
Suffix:
Gender:M
Credentials:AGPCNP
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-526-3005
Mailing Address - Fax:336-526-3011
Practice Address - Street 1:189 SAMARITANS RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2472
Practice Address - Country:US
Practice Address - Phone:336-526-3005
Practice Address - Fax:336-526-3011
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5009435363LA2200X, 363L00000X
GARN224686363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health