Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | MD24743 | OR |
NPI | 1043210248 |
---|---|
Provider Name | Trek Lyons |
First Address | Logan, UT 84341-2408 |
Second Address | Logan, UT 84341-2408 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/07/2005 |
Last Update Date | 06/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H29942 | (02) | UT |