Provider Demographics
NPI:1235639196
Name:MIYASHIRO, LYLE K (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LYLE
Middle Name:K
Last Name:MIYASHIRO
Suffix:
Gender:M
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 1:2159 W GARLAND DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-1884
Mailing Address - Country:US
Mailing Address - Phone:480-567-8202
Mailing Address - Fax:
Practice Address - Street 1:9150 W INDIAN SCHOOL RD STE 131
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037
Practice Address - Country:US
Practice Address - Phone:623-873-0112
Practice Address - Fax:623-873-1370
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-17
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07865363A00000X
AZ7097363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant