Healthcare Provider Details

I. General information

NPI: 1811631872
Provider Name (Legal Business Name): LYNN CARSTEN MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 04/26/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JUNCTION OF HWY 371 AND RT 9
CROWNPOINT NM
87313
US

IV. Provider business mailing address

1506 KIT CARSON DR
GALLUP NM
87301-5914
US

V. Phone/Fax

Practice location:
  • Phone: 505-786-5291
  • Fax:
Mailing address:
  • Phone: 301-221-8334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2305206552
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: