Provider Demographics
NPI:1225013766
Name:HENRICKSON, LYNN ANDRE (MD)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:ANDRE
Last Name:HENRICKSON
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 1:17 LA AGUAPA
Mailing Address - Street 2:
Mailing Address - City:SANDIA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:87047-9676
Mailing Address - Country:US
Mailing Address - Phone:505-286-8027
Mailing Address - Fax:
Practice Address - Street 1:17 LA AGUAPA
Practice Address - Street 2:
Practice Address - City:SANDIA PARK
Practice Address - State:NM
Practice Address - Zip Code:87047-9676
Practice Address - Country:US
Practice Address - Phone:505-286-8027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-02152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology