Provider Demographics
NPI:1730411885
Name:LYONS, TARA MARIE (NP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:LYONS
Suffix:
Gender:F
Credentials:NP
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 8503
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NY
Mailing Address - Zip Code:10803-8503
Mailing Address - Country:US
Mailing Address - Phone:917-226-9836
Mailing Address - Fax:877-636-0628
Practice Address - Street 1:125 PARK DR
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10464-1005
Practice Address - Country:US
Practice Address - Phone:917-226-9836
Practice Address - Fax:877-636-0628
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-31
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430175-1363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP79809Medicare UPIN