Provider Demographics
NPI:1396859203
Name:LYLES, YVONNE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:YVONNE
Middle Name:MARIE
Last Name:LYLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15840 SW ROYALTY PKWY
Mailing Address - Street 2:
Mailing Address - City:KING CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97224-2404
Mailing Address - Country:US
Mailing Address - Phone:302-430-2555
Mailing Address - Fax:
Practice Address - Street 1:19300 SW 65TH AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7706
Practice Address - Country:US
Practice Address - Phone:302-430-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD152774208M00000X, 207QG0300X
WAMD00020322208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR185611Medicare PIN
C93189Medicare UPIN
DE1000032349Medicaid
015585M11Medicare ID - Type Unspecified