Provider Demographics
NPI:1194836296
Name:HAZLETON, LYON TIGE (CRNA)
Entity Type:Individual
Prefix:
First Name:LYON
Middle Name:TIGE
Last Name:HAZLETON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2951 WEST FRONT STREET
Mailing Address - Street 2:SUITE 3050
Mailing Address - City:RICHLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:24641
Mailing Address - Country:US
Mailing Address - Phone:276-963-8504
Mailing Address - Fax:276-963-6642
Practice Address - Street 1:2951 FRONT ST
Practice Address - Street 2:SUITE 3050
Practice Address - City:RICHLANDS
Practice Address - State:VA
Practice Address - Zip Code:24641-2055
Practice Address - Country:US
Practice Address - Phone:276-963-8504
Practice Address - Fax:276-963-6642
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166905367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA194170OtherANTHEM BCBS
WV38100005818Medicaid
VAP00318799OtherRAILROAD MEDICARE
WV38100005818Medicaid