Provider Demographics
NPI:1790113488
Name:LYON, LAUREN (PA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:LYON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 E SUNNYSIDE RD STE G
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8281
Mailing Address - Country:US
Mailing Address - Phone:208-529-8232
Mailing Address - Fax:
Practice Address - Street 1:2375 E SUNNYSIDE RD STE G
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8281
Practice Address - Country:US
Practice Address - Phone:208-529-8232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant