Provider Demographics
NPI:1093126229
Name:LYNESS, COLIN ALAN (MD)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:ALAN
Last Name:LYNESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE DR.
Mailing Address - Street 2:3116 TAUBMAN CENTER, SPC 5368
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-4200
Mailing Address - Fax:208-302-4255
Practice Address - Street 1:1072 N LIBERTY ST
Practice Address - Street 2:STE 303
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-302-4200
Practice Address - Fax:208-302-4255
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-146092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology