Provider Demographics
NPI:1386799328
Name:LYLES, WILLIAM BRADFORD (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRADFORD
Last Name:LYLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 WILLARD DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5204
Mailing Address - Country:US
Mailing Address - Phone:920-497-0788
Mailing Address - Fax:
Practice Address - Street 1:840 WILLARD DR
Practice Address - Street 2:SUITE 201
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5204
Practice Address - Country:US
Practice Address - Phone:920-497-0788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40554-0202084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1386799328Medicare NSC