Healthcare Provider Details

I. General information

NPI: 1811027204
Provider Name (Legal Business Name): MICHAEL LYNN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 WEST A STE. STE #1
MOSCOW ID
83843
US

IV. Provider business mailing address

623 SOUTH MAIN ST. STE #1
MOSCOW ID
83843-2983
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-0540
  • Fax: 208-882-1487
Mailing address:
  • Phone: 208-882-2011
  • Fax: 208-883-1853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number122180
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP-941
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: