Provider Demographics
NPI:1699842948
Name:LYNCH, LISA M (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:LYNCH
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:6520 FORT CAROLINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-2044
Mailing Address - Country:US
Mailing Address - Phone:904-745-3618
Mailing Address - Fax:904-722-4271
Practice Address - Street 1:14444 BEACH BLVD STE 28
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250
Practice Address - Country:US
Practice Address - Phone:904-367-2277
Practice Address - Fax:904-421-3788
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2018-08-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9102266363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016463200Medicaid
FLU2224XMedicare PIN