Provider Demographics
NPI:1164671715
Name:KOVACEVICH, LYNN
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:KOVACEVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 MINOR AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2120
Mailing Address - Country:US
Mailing Address - Phone:206-386-9500
Mailing Address - Fax:206-576-3802
Practice Address - Street 1:515 MINOR AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2120
Practice Address - Country:US
Practice Address - Phone:206-386-9500
Practice Address - Fax:206-576-3802
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO60212170213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01114217OtherRAILROAD MEDICARE
WA0282004OtherDEPT. OF LABOR & INDUSTRIES
WA8901741Medicare PIN