Provider Demographics
NPI:1801952775
Name:LYONS, MARY C (PA)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:C
Last Name:LYONS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:C
Other - Last Name:ENDERLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:109 CALIFORNIA STREET
Mailing Address - Street 2:PO BOX 577
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:618-985-4635
Practice Address - Street 1:400 S LEWIS LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3547
Practice Address - Country:US
Practice Address - Phone:618-519-9901
Practice Address - Fax:519-529-1384
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS72114Medicare UPIN
IL207245Medicare ID - Type UnspecifiedMEDICARE GROUP #
IL214881Medicare PIN
IL7210896OtherAETNA
IL3932056OtherBCBS
IL877242OtherHEALTHLINK
ILK07249Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL #
IL143821Medicare Oscar/Certification
IL037666OtherHAMP
ILK45742Medicare PIN