Healthcare Provider Details

I. General information

NPI: 1285014118
Provider Name (Legal Business Name): LYON MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 E GENTRY WAY STE 100
MERIDIAN ID
83642-3060
US

IV. Provider business mailing address

PO BOX 45179
BOISE ID
83711-5179
US

V. Phone/Fax

Practice location:
  • Phone: 208-947-5390
  • Fax: 208-947-3465
Mailing address:
  • Phone: 208-947-5390
  • Fax: 208-947-3465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANA LYON
Title or Position: CO-OWNER
Credential:
Phone: 208-251-0414