Basic Information
| Provider Information | |||||||||
| NPI: | 1720416985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYONS | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16086 TENOR WAY | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460609287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174353147 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14535A HAZEL DELL PKWY | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460339401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177703777 | ||||||||
| FaxNumber: | 3177054391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2013 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 10001601A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 300009159 | 05 | IN | MEDICAID |