Provider Demographics
NPI:1134245558
Name:TICSON, LYNNE SUSANNE (MD)
Entity type:Individual
Prefix:DR
First Name:LYNNE
Middle Name:SUSANNE
Last Name:TICSON
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 1:44900 N. 60TH ST. WEST
Mailing Address - Street 2:HIGH DESERT HEALTH SYSTEM
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536
Mailing Address - Country:US
Mailing Address - Phone:661-945-8303
Mailing Address - Fax:661-945-8470
Practice Address - Street 1:44900 N. 60TH ST. WEST
Practice Address - Street 2:HIGH DESERT HEALTH SYSTEM
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536
Practice Address - Country:US
Practice Address - Phone:661-945-8303
Practice Address - Fax:661-945-8470
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36279208000000X
CAG36270208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW809AMedicare ID - Type UnspecifiedROYBAL
CAW932Medicare ID - Type UnspecifiedHEALTH CENTER
CAW809FMedicare ID - Type UnspecifiedEL MONTE
CAW809BMedicare ID - Type UnspecifiedHUDSON