Provider Demographics
NPI:1003332560
Name:LYSIUS, MAX FAUBERT (LPN)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:FAUBERT
Last Name:LYSIUS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6303 YULEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-9251
Mailing Address - Country:US
Mailing Address - Phone:315-885-0550
Mailing Address - Fax:
Practice Address - Street 1:6303 YULEWOOD CIR
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-9251
Practice Address - Country:US
Practice Address - Phone:315-885-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328684164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse