Healthcare Provider Details

I. General information

NPI: 1124118377
Provider Name (Legal Business Name): JOHN R. LUNDGREN P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/19/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 JAHNKE RD SUITE 500
RICHMOND VA
23225-4017
US

IV. Provider business mailing address

75 W LEE HWY
WARRENTON VA
20186-2149
US

V. Phone/Fax

Practice location:
  • Phone: 804-320-2751
  • Fax: 804-330-3831
Mailing address:
  • Phone: 610-388-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC5-0001388
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number00110003145
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: