Provider Demographics
NPI:1487681243
Name:LYONS, SUSAN BLAKE (PA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:BLAKE
Last Name:LYONS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 TOUNTAS AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LE ROY
Mailing Address - State:NY
Mailing Address - Zip Code:14482-1368
Mailing Address - Country:US
Mailing Address - Phone:585-767-4220
Mailing Address - Fax:585-768-8165
Practice Address - Street 1:3 TOUNTAS AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:LE ROY
Practice Address - State:NY
Practice Address - Zip Code:14482-1368
Practice Address - Country:US
Practice Address - Phone:585-767-4220
Practice Address - Fax:585-768-8165
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004828363AM0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02395962Medicaid
NY02395962Medicaid
NYH77008 (70008A GROUPMedicare PIN
NYPA0009 (BA0017 GRP)Medicare PIN