Provider Demographics
NPI:1295962983
Name:LYLE, WILLIAM J (CRNA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:LYLE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 S CLIFF AVE
Mailing Address - Street 2:PO BOX 5045 P.F.S.
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1007
Mailing Address - Country:US
Mailing Address - Phone:605-322-2754
Mailing Address - Fax:605-322-2727
Practice Address - Street 1:1325 S CLIFF AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1007
Practice Address - Country:US
Practice Address - Phone:605-322-2754
Practice Address - Fax:605-322-2727
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD-CRNA CR000721367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1295962983Medicaid
NE46022474348Medicaid
SD5756330Medicaid
9281511OtherDAKOTACARE
1295962983OtherMN BCBS
SD5756330Medicaid