Provider Demographics
NPI:1952442535
Name:TAVERA, LYNNE TAMARA (ANP)
Entity Type:Individual
Prefix:MS
First Name:LYNNE
Middle Name:TAMARA
Last Name:TAVERA
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 EL CAMINO REAL STE 11
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3208
Mailing Address - Country:US
Mailing Address - Phone:650-692-1373
Mailing Address - Fax:650-692-4209
Practice Address - Street 1:1750 EL CAMINO REAL STE 11
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3208
Practice Address - Country:US
Practice Address - Phone:650-692-1373
Practice Address - Fax:650-692-4209
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13288363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ71317ZMedicaid
CAZZZ71317ZMedicaid
CAA40340Medicare UPIN