Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NN0400X | Neurology | 038007551 | IL |
Y | 111NN0400X | Neurology | DCP00601 | RI |
NPI | 1407926884 |
---|---|
Provider Name | Dr. Richard Thad Lyon |
First Address | Cranston, RI 02910-2346 |
Second Address | Cranston, RI 02910-2346 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/11/2006 |
Last Update Date | 10/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
04506397 | BLUE CROSS BLUE SHIELD (01) | IL |
U452540 | (02) | IL |