MEDICARE: MS. LUCETTA LYNNE LYFORD PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	5601003467	MI

General Provider Information

NPI Number	:	1396749800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LUCETTA LYNNE LYFORD PA-C

Provider Business Mailing Address
First Line	:	430 W. CENTRE AVE.
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024
Country	:	US
Telephone Number	:	269-321-6673
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 W. CENTRE AVE.
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024
Country	:	US
Telephone Number	:	269-321-6673
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	08/07/2007

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