Provider Demographics
NPI:1811927890
Name:MASTERVICH, LYNNE A (PA)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:A
Last Name:MASTERVICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LYNNE
Other - Middle Name:A
Other - Last Name:MCMEANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1838 GREENE TREE ROAD
Mailing Address - Street 2:SUITE 150- LL
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208
Mailing Address - Country:US
Mailing Address - Phone:410-602-9262
Mailing Address - Fax:410-602-9276
Practice Address - Street 1:7501 OSLER DR
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7736
Practice Address - Country:US
Practice Address - Phone:410-583-1170
Practice Address - Fax:410-583-1267
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002809363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q18793Medicare UPIN
000LK967Medicare ID - Type Unspecified