Provider Demographics
NPI:1245830942
Name:LYSNE, JIM ROBERT
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:ROBERT
Last Name:LYSNE
Suffix:
Gender:M
Credentials:
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 831
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-0831
Mailing Address - Country:US
Mailing Address - Phone:319-693-1090
Mailing Address - Fax:
Practice Address - Street 1:3032 14TH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IA
Practice Address - Zip Code:52302-1524
Practice Address - Country:US
Practice Address - Phone:319-693-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)