Provider Demographics
NPI:1891904546
Name:LYON, SHAUNNA M (MD)
Entity Type:Individual
Prefix:
First Name:SHAUNNA
Middle Name:M
Last Name:LYON
Suffix:
Gender:F
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:N2950 STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2655
Mailing Address - Country:US
Mailing Address - Phone:262-245-0535
Mailing Address - Fax:262-245-2248
Practice Address - Street 1:N2950 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2655
Practice Address - Country:US
Practice Address - Phone:262-245-0535
Practice Address - Fax:262-245-2248
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-7249208000000X
IA37206208000000X
WI55298-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WILYONSHAOtherMERCYCARE INSURANCE
WI1891904546Medicaid
IA54309OtherWELLMARK BCBS
WILYONSHAOtherMERCYCARE INSURANCE
IA54309OtherWELLMARK BCBS
WI1891904546Medicaid