Basic Information
| Provider Information | |||||||||
| NPI: | 1104213206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYONS | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 AIRPORT GARDENS ROAD | ||||||||
| Address2: | CREDENTIALING AND PROVIDER ENROLLMENT | ||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064877503 | ||||||||
| FaxNumber: | 6064325363 | ||||||||
| Practice Location | |||||||||
| Address1: | 9879 KY ROUTE 122 | ||||||||
| Address2: | |||||||||
| City: | MC DOWELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 416476026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063773427 | ||||||||
| FaxNumber: | 6063773466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2015 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 04160 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100510970 | 05 | KY | MEDICAID |