Provider Demographics
NPI:1083662761
Name:LYSIUK, LEE NATHAN (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:NATHAN
Last Name:LYSIUK
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10752 CHESTNUT HEATH CT
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-6117
Mailing Address - Country:US
Mailing Address - Phone:317-417-8689
Mailing Address - Fax:
Practice Address - Street 1:8227 NORTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1387
Practice Address - Country:US
Practice Address - Phone:317-415-5747
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001149A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer