Provider Demographics
NPI:1811027204
Name:LYNN, MICHAEL (NP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:LYNN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 SOUTH MAIN ST.
Mailing Address - Street 2:STE #1
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2983
Mailing Address - Country:US
Mailing Address - Phone:208-882-2011
Mailing Address - Fax:208-883-1853
Practice Address - Street 1:2500 WEST A STE.
Practice Address - Street 2:STE #1
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:208-882-0540
Practice Address - Fax:208-882-1487
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO122180363L00000X
IDNP-941363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO122180OtherNURSING LICENSE #
IDNP-941OtherIDAHO NURSING LICENSE