Provider Demographics
NPI:1548257652
Name:LYONS, TOMMY W (CRNA)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:W
Last Name:LYONS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 FOX RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-2475
Mailing Address - Country:US
Mailing Address - Phone:419-232-2866
Mailing Address - Fax:419-232-2867
Practice Address - Street 1:1250 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-2551
Practice Address - Country:US
Practice Address - Phone:419-232-2866
Practice Address - Fax:419-232-2867
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN271691163W00000X
OHNA71515367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00241523OtherMEDICARE RAILROAD INDV.
OH2495250Medicaid
OH20290372400OtherWORKMENS COMP
OH000000373810OtherANTHEM BC/BS
OH202903724OtherMEDICAL MUTUAL
OH202903724OtherMEDICAL MUTUAL