Provider Demographics
NPI:1285797258
Name:TULLER, LYNN C (PA)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:C
Last Name:TULLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W CRYSTAL LAKE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-4475
Mailing Address - Country:US
Mailing Address - Phone:407-254-2500
Mailing Address - Fax:407-423-2789
Practice Address - Street 1:25 W CRYSTAL LAKE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4475
Practice Address - Country:US
Practice Address - Phone:407-254-2500
Practice Address - Fax:407-423-2789
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103793363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9103793OtherMEDICAL LICENSE
FLP01366212OtherRAILROAD MEDICARE
FL292718700Medicaid
FLAD212Medicare PIN
FLP01366212OtherRAILROAD MEDICARE
FLBS932ZMedicare PIN
FLAD212XMedicare PIN