Provider Demographics
NPI:1770961047
Name:LYONS, ROBERT (PTA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LYONS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16705 SOUTH POINT DR
Mailing Address - Street 2:
Mailing Address - City:NEHALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97131
Mailing Address - Country:US
Mailing Address - Phone:503-322-8465
Mailing Address - Fax:
Practice Address - Street 1:280 ROWE ST
Practice Address - Street 2:
Practice Address - City:WHEELER
Practice Address - State:OR
Practice Address - Zip Code:97147
Practice Address - Country:US
Practice Address - Phone:503-368-5171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07723174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist