Healthcare Provider Details

I. General information

NPI: 1952965733
Provider Name (Legal Business Name): JOHN SHANNON LYERLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CRITTENDEN BLVD
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

300 CRITTENDEN BLVD
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-6917
  • Fax: 585-276-2292
Mailing address:
  • Phone: 585-275-6917
  • Fax: 585-276-2292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA196992
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: