Provider Demographics
NPI:1619295714
Name:LYON, JONATHAN AVERY (DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:AVERY
Last Name:LYON
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 140TH AVENUE NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005
Mailing Address - Country:US
Mailing Address - Phone:425-746-2475
Mailing Address - Fax:425-746-2471
Practice Address - Street 1:3200 W. MCGRAW STREET
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199
Practice Address - Country:US
Practice Address - Phone:206-281-7970
Practice Address - Fax:425-746-2471
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60146373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0280803OtherDEPT. OF LABOR AND INDUSTRIES
WAG8901436Medicare PIN
WAG8901437Medicare PIN