Provider Demographics
NPI:1609487735
Name:LYONS, JORDAN VERDIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:VERDIE
Last Name:LYONS
Suffix:
Gender:F
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 1:635 BELLE TERRE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1977
Mailing Address - Country:US
Mailing Address - Phone:631-474-0008
Mailing Address - Fax:
Practice Address - Street 1:635 BELLE TERRE RD STE 204
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1977
Practice Address - Country:US
Practice Address - Phone:631-474-0008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025252363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty