Provider Demographics
NPI:1336582048
Name:LYONS, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LYONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 11TH AVE S
Mailing Address - Street 2:APT 511
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-1414
Mailing Address - Country:US
Mailing Address - Phone:218-391-0218
Mailing Address - Fax:
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:HENNEPIN COUNTY MEDICAL CENTER
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-6963
Practice Address - Fax:612-904-4263
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN61310207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine