Provider Demographics
NPI:1124118377
Name:LUNDGREN, JOHN R (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:LUNDGREN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 W LEE HWY
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-2149
Mailing Address - Country:US
Mailing Address - Phone:610-388-6600
Mailing Address - Fax:
Practice Address - Street 1:7101 JAHNKE RD
Practice Address - Street 2:SUITE 500
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4017
Practice Address - Country:US
Practice Address - Phone:804-320-2751
Practice Address - Fax:804-330-3831
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001388363AS0400X
VA00110003145363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN
VAC06778OtherGROUP PTAN