Provider Demographics
NPI:1063502763
Name:LYNASS, BRETT A (PT)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:A
Last Name:LYNASS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 JUNCTION AVENUE
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-2124
Mailing Address - Country:US
Mailing Address - Phone:605-720-2555
Mailing Address - Fax:605-720-2560
Practice Address - Street 1:1530 JUNCTION AVENUE
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-2124
Practice Address - Country:US
Practice Address - Phone:605-720-2555
Practice Address - Fax:605-720-2560
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0245225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5831193Medicaid
SDS101850Medicare PIN