Provider Demographics
NPI:1376998690
Name:LYSKAWA, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LYSKAWA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 FAIRWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT RIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48069-1217
Mailing Address - Country:US
Mailing Address - Phone:248-342-2885
Mailing Address - Fax:
Practice Address - Street 1:64 FAIRWOOD BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANT RIDGE
Practice Address - State:MI
Practice Address - Zip Code:48069-1217
Practice Address - Country:US
Practice Address - Phone:248-342-2885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other