Provider Demographics
NPI:1164596128
Name:LYON, ANGHARAD SUPE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:ANGHARAD
Middle Name:SUPE
Last Name:LYON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4063
Mailing Address - Country:US
Mailing Address - Phone:208-282-2330
Mailing Address - Fax:208-282-4036
Practice Address - Street 1:ISU STUDENT HEALTH CTR
Practice Address - Street 2:921 S. 8TH ST.
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-2330
Practice Address - Fax:208-282-4036
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-365390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program