Provider Demographics
NPI:1316114465
Name:LENZ, LYNETTE MYRA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LYNETTE
Middle Name:MYRA
Last Name:LENZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LYNETTE
Other - Middle Name:MYRA
Other - Last Name:NIKKHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1155 MISSION ST SE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-362-6304
Mailing Address - Fax:503-362-5570
Practice Address - Street 1:1155 MISSION ST SE
Practice Address - Street 2:SUITE 205
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-362-6304
Practice Address - Fax:503-362-5570
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01354363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR141798Medicare UPIN