Provider Demographics
NPI:1669528741
Name:LYONS, KENNETH D (PA-C)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:D
Last Name:LYONS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:SILOAM
Mailing Address - State:NC
Mailing Address - Zip Code:27047-9177
Mailing Address - Country:US
Mailing Address - Phone:336-374-2806
Mailing Address - Fax:
Practice Address - Street 1:799 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4206
Practice Address - Country:US
Practice Address - Phone:336-703-3316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101183363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101183OtherMEDICAL BOARD NUMBER
NCZA0000009Medicaid