Healthcare Provider Details

I. General information

NPI: 1659920890
Provider Name (Legal Business Name): ZACHARY RYAN LYNCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 09/02/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 JB WISE PLACE
WATERTOWN NY
13601-2507
US

IV. Provider business mailing address

PO BOX 6550
WATERTOWN NY
13601-6550
US

V. Phone/Fax

Practice location:
  • Phone: 315-779-1184
  • Fax:
Mailing address:
  • Phone: 315-788-7430
  • Fax: 315-785-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF403145
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: