Provider Demographics
NPI:1790008175
Name:LYNCH, GREGORY K (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:K
Last Name:LYNCH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 S MAIN ST STE 215
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-2533
Mailing Address - Country:US
Mailing Address - Phone:951-525-3548
Mailing Address - Fax:951-525-3563
Practice Address - Street 1:2815 S MAIN ST STE 215
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-2533
Practice Address - Country:US
Practice Address - Phone:951-525-3548
Practice Address - Fax:951-525-3563
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20639363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA20639OtherLICENSE NUMBER