Provider Demographics
NPI:1598730434
Name:LYLE, TOM (ATC)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:LYLE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3464 NE RAINIER LOOP
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1747
Mailing Address - Country:US
Mailing Address - Phone:928-527-1531
Mailing Address - Fax:
Practice Address - Street 1:400 W ELM AVE
Practice Address - Street 2:FLAGSTAFF HIGH SCHOOL
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1562
Practice Address - Country:US
Practice Address - Phone:928-527-1531
Practice Address - Fax:928-773-8146
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0036174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist