Provider Demographics
NPI:1831114040
Name:LYNCH, JUSTIN R (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:R
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:PO BOX 63362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3362
Mailing Address - Country:US
Mailing Address - Phone:800-782-6945
Mailing Address - Fax:
Practice Address - Street 1:3475 ERWIN RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-0005
Practice Address - Country:US
Practice Address - Phone:919-668-1400
Practice Address - Fax:919-684-8595
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0650363A00000X
NC0010-06663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30336484Medicaid
NH30336484Medicaid