Provider Demographics
NPI:1740210061
Name:LYLE, MATTHEW LAMAR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LAMAR
Last Name:LYLE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0011
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:433 PLAZA ST
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3729
Practice Address - Country:US
Practice Address - Phone:985-730-6700
Practice Address - Fax:985-730-6713
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN089353367500000X
ARC02817367500000X
LAAPO4029367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR183618001Medicaid
MO1740210061Medicaid
OK200497160AMedicaid
AR5V610C741Medicare UPIN