Provider Demographics
NPI:1962803361
Name:NOVRUZOV, LYDIA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:
Last Name:NOVRUZOV
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 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7664
Mailing Address - Country:US
Mailing Address - Phone:276-258-1800
Mailing Address - Fax:276-258-1805
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7664
Practice Address - Country:US
Practice Address - Phone:276-258-1800
Practice Address - Fax:276-258-1805
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005362363AM0700X
MO2014030522363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1962803361Medicaid
VAVVL714AMedicare PIN