MEDICARE: MS. ALLISON D LY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA9100938	FL
2	363A00000X	Physician Assistant	PA9100938	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255388815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ALLISON D LY PA-C

Provider Business Mailing Address
First Line	:	367 S. GULPH RD
Second Line	:	ATTN: IPM CREDENTIALING
City	:	KING OF PRUSSIA
State	:	PA
Zip	:	19406-3121
Country	:	US
Telephone Number	:	561-333-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3319 S STATE ROAD 7 STE 102
Second Line	:
City	:	WELLINGTON
State	:	FL
Zip	:	33449-8099
Country	:	US
Telephone Number	:	561-333-4000
Fax Number	:	561-333-8851

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	07/08/2019

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