Provider Demographics
NPI:1417144759
Name:GLYNNIS J. LYONS, DO, PA
Entity Type:Organization
Organization Name:GLYNNIS J. LYONS, DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GLYNNIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:772-286-0552
Mailing Address - Street 1:2489 SE DELANO RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5541
Mailing Address - Country:US
Mailing Address - Phone:772-286-0552
Mailing Address - Fax:772-286-7574
Practice Address - Street 1:1050 SE MONTEREY RD
Practice Address - Street 2:SUITE #201
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4512
Practice Address - Country:US
Practice Address - Phone:772-286-0552
Practice Address - Fax:772-286-7574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9199Medicare PIN
FLE35052Medicare UPIN
FL82449Medicare PIN