Healthcare Provider Details

I. General information

NPI: 1578956371
Provider Name (Legal Business Name): AMANDA J LYNN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EMILE @ 42ND
OMAHA NE
68198-0001
US

IV. Provider business mailing address

825 S. 169TH ST. 3RD FLOOR - SOUTH
OMAHA NE
68118
US

V. Phone/Fax

Practice location:
  • Phone: 25-594-4424
  • Fax:
Mailing address:
  • Phone: 402-354-4822
  • Fax: 402-354-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number666
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2491
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2491
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: