Healthcare Provider Details

I. General information

NPI: 1841208394
Provider Name (Legal Business Name): LYNETTE MARIE AZURE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 4TH ST SE
DEVILS LAKE ND
58301-3610
US

IV. Provider business mailing address

320 4TH ST SE
DEVILS LAKE ND
58301-3610
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-8128
  • Fax:
Mailing address:
  • Phone: 701-662-8128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2600
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: