Provider Demographics
NPI:1912951278
Name:DORMAN, LYLE CHANEY (CRNA)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:CHANEY
Last Name:DORMAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5061 SUSSEX DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-8232
Mailing Address - Country:US
Mailing Address - Phone:706-868-8203
Mailing Address - Fax:
Practice Address - Street 1:200 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2981
Practice Address - Country:US
Practice Address - Phone:478-275-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149260367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA618336666BMedicaid
GA618336666BMedicaid
GA43BBCCCMedicare PIN