Provider Demographics
NPI:1770938003
Name:LYNCH, MARK ALAN (FNP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:LYNCH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 SW RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5808
Mailing Address - Country:US
Mailing Address - Phone:541-507-2290
Mailing Address - Fax:
Practice Address - Street 1:625 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5808
Practice Address - Country:US
Practice Address - Phone:541-507-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-23
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10011966363LX0106X
COC-APN.0000524-C-NP363L00000X
ID66220363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1770938003Medicaid