Provider Demographics
NPI:1902050420
Name:LYONS, MARY ELLEN (PA)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:LYONS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:340 MONTAGE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MOOSIC
Mailing Address - State:PA
Mailing Address - Zip Code:18507-1782
Mailing Address - Country:US
Mailing Address - Phone:570-344-9266
Mailing Address - Fax:570-344-1085
Practice Address - Street 1:340 MONTAGE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MOOSIC
Practice Address - State:PA
Practice Address - Zip Code:18507-1782
Practice Address - Country:US
Practice Address - Phone:570-344-9266
Practice Address - Fax:570-344-1085
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001524L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant