Provider Demographics
NPI:1316152341
Name:LYLE, ANN BLACK (MD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:BLACK
Last Name:LYLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2511 MEDINA CIR
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:WA
Mailing Address - Zip Code:98039-1503
Mailing Address - Country:US
Mailing Address - Phone:425-455-4545
Mailing Address - Fax:
Practice Address - Street 1:2700 NORTHUP WAY
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-1463
Practice Address - Country:US
Practice Address - Phone:425-827-4600
Practice Address - Fax:425-828-2256
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025209 MD00017466208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG51383Medicare UPIN
WAAB00623Medicare ID - Type Unspecified