Provider Demographics
NPI:1750453361
Name:HARRISON, LYLE (MD)
Entity Type:Individual
Prefix:DR
First Name:LYLE
Middle Name:
Last Name:HARRISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781378
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67278-1378
Mailing Address - Country:US
Mailing Address - Phone:316-321-8780
Mailing Address - Fax:316-321-8723
Practice Address - Street 1:720 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2112
Practice Address - Country:US
Practice Address - Phone:316-321-8780
Practice Address - Fax:316-321-8723
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND76662085R0001X
KS04411262085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSEA5581OtherRADIATION ONCOLOGY
KS201205230AMedicaid
NDN711728Medicare ID - Type UnspecifiedND MEDICARE NUMBER
ND017365OtherBLUE CROSS BLUE SHIELD ND