Provider Demographics
NPI:1942245824
Name:SUDDUTH, LYNN SUSANNE (MD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:SUSANNE
Last Name:SUDDUTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9621 RIDGETOP BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19245 7TH AVE NE
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7504
Practice Address - Country:US
Practice Address - Phone:360-782-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024682207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
070012924OtherRAILROAD MEDICARE
WA100670OtherLABOR & INDUSTRIES
WA1089853Medicaid
1918SUOtherREGENCE BLUESHIELD
4648199OtherAETNA
4648199OtherAETNA
070012924OtherRAILROAD MEDICARE
WA100670OtherLABOR & INDUSTRIES
WAGAB08648Medicare PIN
WAGAB08647Medicare PIN
1918SUOtherREGENCE BLUESHIELD
G8888143Medicare PIN
BS4201187OtherDEA
F95215Medicare UPIN