Healthcare Provider Details

I. General information

NPI: 1972738656
Provider Name (Legal Business Name): TRENT W LYONS M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2009
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 NEW SCOTLAND AVE RADIOLOGY DEPT
ALBANY NY
12208-3412
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD SUITE 201
LATHAM NY
12110-2442
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-3277
  • Fax: 518-262-4210
Mailing address:
  • Phone: 518-783-3700
  • Fax: 518-782-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number256228
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: