=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023262797
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY E LYON-LOFTUS PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2008
-----------------------------------------------------
Last Update Date | 04/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19917 7TH AVENUE SUITE 205
-----------------------------------------------------
City | POULSBO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-779-1963
-----------------------------------------------------
Fax | 360-779-6449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 960
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-478-2366
-----------------------------------------------------
Fax | 360-373-2096
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA60055159
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------