Provider Demographics
NPI:1609833359
Name:VANWAGNEN, LYNN CLARK (MD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:CLARK
Last Name:VANWAGNEN
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 1:1310 GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3077
Mailing Address - Country:US
Mailing Address - Phone:517-787-1990
Mailing Address - Fax:517-787-1983
Practice Address - Street 1:1310 GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-3077
Practice Address - Country:US
Practice Address - Phone:517-787-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038051207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110241201OtherRR MEDICARE
MI101587882Medicaid
MIN53130009Medicare ID - Type UnspecifiedWA FOOTE MEMORIAL
MI101587882Medicaid