Provider Demographics
NPI:1760401244
Name:KOSANOVIC, LYNN WYNNE (CRNA)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:WYNNE
Last Name:KOSANOVIC
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 SW 9TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321
Mailing Address - Country:US
Mailing Address - Phone:541-926-9611
Mailing Address - Fax:541-926-6152
Practice Address - Street 1:930 SW 9TH AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321
Practice Address - Country:US
Practice Address - Phone:541-926-9611
Practice Address - Fax:541-926-6152
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR82012809174400000X
OR082012809367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213481Medicaid
OR213481Medicaid
OR102865Medicare ID - Type Unspecified