1720416985 NPI number — TRACI M LYONS PA-C

Table of content: TRACI M LYONS PA-C (NPI 1720416985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720416985 NPI number — TRACI M LYONS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYONS
Provider First Name:
TRACI
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720416985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16086 TENOR WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOBLESVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46060-9287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-435-3147
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14535A HAZEL DELL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46033-9401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-770-3777
Provider Business Practice Location Address Fax Number:
317-705-4391
Provider Enumeration Date:
10/28/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  10001601A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300009159 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".