Healthcare Provider Details

I. General information

NPI: 1811065501
Provider Name (Legal Business Name): JOHN J LYONS IV MASTER OF SCIENCE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 COLUMBIA ST
HUDSON NY
12534-1905
US

IV. Provider business mailing address

325 COLUMBIA ST
HUDSON NY
12534-1905
US

V. Phone/Fax

Practice location:
  • Phone: 518-828-9446
  • Fax: 518-828-9450
Mailing address:
  • Phone: 518-828-9446
  • Fax: 518-828-9450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: