Provider Demographics
NPI:1942598214
Name:LYONS, NATHANIEL GAGE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:GAGE
Last Name:LYONS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:NATHANIEL
Other - Middle Name:G
Other - Last Name:LYONS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:2200 FORT JESSE RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6286
Mailing Address - Country:US
Mailing Address - Phone:309-888-9800
Mailing Address - Fax:866-888-9198
Practice Address - Street 1:2200 FORT JESSE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6286
Practice Address - Country:US
Practice Address - Phone:309-888-9800
Practice Address - Fax:866-888-9198
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018612225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist