Provider Demographics
NPI:1366774234
Name:LYONS, LANCE BRADFORD (PA-C)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:BRADFORD
Last Name:LYONS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 79TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4427
Mailing Address - Country:US
Mailing Address - Phone:727-647-8259
Mailing Address - Fax:
Practice Address - Street 1:2020 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4604
Practice Address - Country:US
Practice Address - Phone:941-792-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-03
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105357363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant