Healthcare Provider Details

I. General information

NPI: 1366445157
Provider Name (Legal Business Name): KATHLEEN DIANE TYNDALL P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45104 10TH ST W
LANCASTER CA
93534-2310
US

IV. Provider business mailing address

45104 10TH ST W
LANCASTER CA
93534-2310
US

V. Phone/Fax

Practice location:
  • Phone: 562-867-7999
  • Fax:
Mailing address:
  • Phone: 562-867-7999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12152
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: