Provider Demographics
NPI:1962116962
Name:FALES, LYDIA (PA-C)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:FALES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:
Other - Last Name:DEN DULK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4100 EMBASSY DR SE STE 400
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2416
Mailing Address - Country:US
Mailing Address - Phone:616-570-2820
Mailing Address - Fax:
Practice Address - Street 1:4100 EMBASSY DR SE STE 400
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2416
Practice Address - Country:US
Practice Address - Phone:616-988-8220
Practice Address - Fax:616-957-3220
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011578363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant