Provider Demographics
NPI:1730244542
Name:LYSNE, MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:LYSNE
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 1:415 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2431
Mailing Address - Country:US
Mailing Address - Phone:208-743-2511
Mailing Address - Fax:208-799-5554
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-743-2511
Practice Address - Fax:208-799-5554
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5825207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8K552OtherBLUE CROSS OF ID GROUP NU
ID10003076OtherREGENCE OF ID URGENT CARE
IDHBRR0OtherBLUE CROSS OF IDAHO IND
ID003805700Medicaid
WA8128159Medicaid
ID10003077OtherREGENCE OF IDAHO
WA8128159Medicaid
IDHBRR0OtherBLUE CROSS OF IDAHO IND
ID8K552OtherBLUE CROSS OF ID GROUP NU