Provider Demographics
NPI:1255913760
Name:LYNUM, DAVID BRUCE NEITZEL
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:BRUCE NEITZEL
Last Name:LYNUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14409 GUTHRIE WAY
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-6377
Mailing Address - Country:US
Mailing Address - Phone:612-968-7005
Mailing Address - Fax:
Practice Address - Street 1:15265 CARROUSEL WAY
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-1760
Practice Address - Country:US
Practice Address - Phone:952-443-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program