Provider Demographics
NPI:1699712034
Name:LYONS, ROBERT A (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:LYONS
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:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6500
Mailing Address - Fax:208-955-6503
Practice Address - Street 1:1623 S. WELLS AVENUE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-489-1450
Practice Address - Fax:208-489-1451
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8869207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806678200Medicaid
ID1112413Medicare PIN
P00239993Medicare PIN
ID806678200Medicaid