Provider Demographics
NPI:1104138551
Name:LYNCH, DOUGLAS PATRICK (DPT)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:PATRICK
Last Name:LYNCH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-9552
Mailing Address - Country:US
Mailing Address - Phone:801-834-1792
Mailing Address - Fax:
Practice Address - Street 1:2118 LEXINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:801-834-1792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT2568225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist