Provider Demographics
NPI:1093101875
Name:LYON, MARY ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:LYON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2140
Mailing Address - Country:US
Mailing Address - Phone:213-713-5674
Mailing Address - Fax:
Practice Address - Street 1:YALE MEDICAL SCHOOL
Practice Address - Street 2:333 CEDAR ST
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510
Practice Address - Country:US
Practice Address - Phone:213-713-5674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66793207P00000X
CT60501207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine