Provider Demographics
NPI:1346880697
Name:LYONS, WESLEY CORLISS (PA-C)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:CORLISS
Last Name:LYONS
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 1:725 BROOK RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-8086
Mailing Address - Country:US
Mailing Address - Phone:319-361-7259
Mailing Address - Fax:
Practice Address - Street 1:502 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:IA
Practice Address - Zip Code:52349-2254
Practice Address - Country:US
Practice Address - Phone:319-472-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA099516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant