Healthcare Provider Details

I. General information

NPI: 1588227797
Provider Name (Legal Business Name): DANE PHILLIP LYMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 S 300 W
BLANDING UT
84511-3921
US

IV. Provider business mailing address

PO BOX 130
MONTEZUMA CREEK UT
84534-0130
US

V. Phone/Fax

Practice location:
  • Phone: 435-678-0700
  • Fax: 435-678-0707
Mailing address:
  • Phone: 435-651-3700
  • Fax: 435-678-0707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11982449-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: