MEDICARE: MARY T LYNCH RPA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	006876	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	J400002702	OTHER	NY	PTAN#

General Provider Information

NPI Number	:	1659331080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY T LYNCH RPA

Provider Business Mailing Address
First Line	:	4101 MEDICAL CENTER DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-6600
Country	:	US
Telephone Number	:	315-637-7800
Fax Number	:	315-637-7800

Provider Business Practice Location Address
First Line	:	4101 MEDICAL CENTER DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-6600
Country	:	US
Telephone Number	:	315-637-7800
Fax Number	:	315-637-7800

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	10/09/2009

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