Basic Information
| Provider Information | |||||||||
| NPI: | 1245423946 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | F. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 30110 CROWN VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | LAGUNA NIGUEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926772043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494957144 | ||||||||
| FaxNumber: | 9494950270 | ||||||||
| Practice Location | |||||||||
| Address1: | 30110 CROWN VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | LAGUNA NIGUEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926772043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494957144 | ||||||||
| FaxNumber: | 9494950270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2007 | ||||||||
| LastUpdateDate: | 08/25/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | C27618 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | 261QP2300X | C276180 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 00C276180 | 01 | CA | BLUE SHIELD | OTHER | 00C276180 | 05 | CA | MEDICAID |