Provider Demographics
NPI:1841208394
Name:AZURE, LYNETTE MARIE (PA)
Entity Type:Individual
Prefix:MS
First Name:LYNETTE
Middle Name:MARIE
Last Name:AZURE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 4TH ST SE
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-3610
Mailing Address - Country:US
Mailing Address - Phone:701-662-8128
Mailing Address - Fax:
Practice Address - Street 1:320 4TH ST SE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-3610
Practice Address - Country:US
Practice Address - Phone:701-662-8128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2600363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical