MEDICARE: MS. LYNNETTE GROEGER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	268	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154308245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LYNNETTE GROEGER PA-C

Provider Business Mailing Address
First Line	:	340 PRINTERS PKWY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-3190
Country	:	US
Telephone Number	:	719-630-6440
Fax Number	:	719-228-6609

Provider Business Practice Location Address
First Line	:	2840 INTERNATIONAL CIR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-3127
Country	:	US
Telephone Number	:	719-640-6440
Fax Number	:	719-228-6609

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	07/08/2007

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