Provider Demographics
NPI:1356551220
Name:LYNCH, SHAUNA
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:LYNCH
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 1:504 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-6917
Mailing Address - Country:US
Mailing Address - Phone:805-739-3474
Mailing Address - Fax:
Practice Address - Street 1:877 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3292
Practice Address - Country:US
Practice Address - Phone:805-474-8450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11056207Q00000X
AZ4502207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program