Healthcare Provider Details

I. General information

NPI: 1639802283
Provider Name (Legal Business Name): MADISON LYFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 HARRY L DR
JOHNSON CITY NY
13790-1423
US

IV. Provider business mailing address

PO BOX 66
PORT CRANE NY
13833-0066
US

V. Phone/Fax

Practice location:
  • Phone: 607-777-9475
  • Fax:
Mailing address:
  • Phone: 607-237-1548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: