1598881203 NPI number — DR. LYNN M PANGBURN DC

Table of content: DR. LYNN M PANGBURN DC (NPI 1598881203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598881203 NPI number — DR. LYNN M PANGBURN DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANGBURN
Provider First Name:
LYNN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KNUTH
Provider Other First Name:
LYNN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598881203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1830 S ALMA SCHOOL RD
Provider Second Line Business Mailing Address:
STE 135
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85210-3056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-839-2273
Provider Business Mailing Address Fax Number:
480-907-3061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1830 S ALMA SCHOOL RD
Provider Second Line Business Practice Location Address:
STE 135
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85210-3056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-839-2273
Provider Business Practice Location Address Fax Number:
480-907-3061
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  7610 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AZ0402700 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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