Provider Demographics
NPI:1710956354
Name:MARKINAC, LYNNE BUSAM (NP)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:BUSAM
Last Name:MARKINAC
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LYNNE
Other - Middle Name:
Other - Last Name:BUSAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8053
Mailing Address - Fax:617-421-3487
Practice Address - Street 1:230 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-5420
Practice Address - Country:US
Practice Address - Phone:781-431-5200
Practice Address - Fax:781-431-5298
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA135572363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0360431Medicaid
MANP1113OtherBLUE CROSS
MAN411OtherHARVARD PILGRIM
MANP1113OtherBLUE CROSS
MANP1113Medicare ID - Type Unspecified