Provider Demographics
NPI:1700977956
Name:LYERLA, JULIE LOUISE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:LOUISE
Last Name:LYERLA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:LYON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:528 STOUGHTON RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-1137
Mailing Address - Country:US
Mailing Address - Phone:608-884-2544
Mailing Address - Fax:608-884-2912
Practice Address - Street 1:528 STOUGHTON RD
Practice Address - Street 2:SUITE 2
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-1137
Practice Address - Country:US
Practice Address - Phone:608-884-2544
Practice Address - Fax:608-884-2912
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI409023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32445200Medicaid
G77970Medicare UPIN