Basic Information
Provider Information | |||||||||
NPI: | 1497732689 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LYONS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | F | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | II | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1112 6TH AVE | ||||||||
Address2: | 200 | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984054040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2532728664 | ||||||||
FaxNumber: | 2534288136 | ||||||||
Practice Location | |||||||||
Address1: | 1112 6TH AVE | ||||||||
Address2: | 200 | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984054040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2532728664 | ||||||||
FaxNumber: | 2534288136 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD23549 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | LY2347 | 01 |   | REGENCE | OTHER | 77667 | 01 | WA | LABOR & INDUSTRIES | OTHER | 8123978 | 05 | WA |   | MEDICAID |