Healthcare Provider Details

I. General information

NPI: 1417450750
Provider Name (Legal Business Name): TRAVIS A LYON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 12/16/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15301 WARREN SHINGLE RD
BEALE AFB CA
95903-1905
US

IV. Provider business mailing address

15301 WARREN SHINGLE RD
BEALE AFB CA
95903-1905
US

V. Phone/Fax

Practice location:
  • Phone: 530-634-2941
  • Fax:
Mailing address:
  • Phone: 530-634-2941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17929
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: