Healthcare Provider Details

I. General information

NPI: 1700977956
Provider Name (Legal Business Name): JULIE LOUISE LYERLA PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIE LYON

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 STOUGHTON RD SUITE 2
EDGERTON WI
53534-1137
US

IV. Provider business mailing address

528 STOUGHTON RD SUITE 2
EDGERTON WI
53534-1137
US

V. Phone/Fax

Practice location:
  • Phone: 608-884-2544
  • Fax: 608-884-2912
Mailing address:
  • Phone: 608-884-2544
  • Fax: 608-884-2912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number409023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: