Healthcare Provider Details

I. General information

NPI: 1154308245
Provider Name (Legal Business Name): LYNNETTE GROEGER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2840 INTERNATIONAL CIR
COLORADO SPRINGS CO
80910-3127
US

IV. Provider business mailing address

340 PRINTERS PKWY
COLORADO SPRINGS CO
80910-3190
US

V. Phone/Fax

Practice location:
  • Phone: 719-640-6440
  • Fax: 719-228-6609
Mailing address:
  • Phone: 719-630-6440
  • Fax: 719-228-6609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number268
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: