Provider Demographics
NPI:1679650097
Name:LYONS, TRACY (DC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:LYONS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 WALTON DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-5022
Mailing Address - Country:US
Mailing Address - Phone:920-892-4322
Mailing Address - Fax:
Practice Address - Street 1:825 WALTON DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-5022
Practice Address - Country:US
Practice Address - Phone:920-892-4322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3187111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38887000Medicaid
WI38887000Medicaid