Provider Demographics
NPI:1992862502
Name:JOSELYN, LYNN MARIE
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:MARIE
Last Name:JOSELYN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1372 AVENIDA DEL SOL
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4973
Mailing Address - Country:US
Mailing Address - Phone:512-291-5624
Mailing Address - Fax:
Practice Address - Street 1:2577 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5919
Practice Address - Country:US
Practice Address - Phone:970-247-8382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0000975363A00000X
TXPA02744363A00000X
NMPA2015-0049363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ37975Medicare UPIN