Provider Demographics
NPI:1144429507
Name:LYLE, TONY WAYNE (NAVY IDC)
Entity Type:Individual
Prefix:MR
First Name:TONY
Middle Name:WAYNE
Last Name:LYLE
Suffix:
Gender:M
Credentials:NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 LAKE VICTORIA DR.
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548
Mailing Address - Country:US
Mailing Address - Phone:912-322-8352
Mailing Address - Fax:
Practice Address - Street 1:1061 USS TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:KINGS BAY
Practice Address - State:GA
Practice Address - Zip Code:31547
Practice Address - Country:US
Practice Address - Phone:912-573-4540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman