Provider Demographics
NPI:1386752269
Name:VANTHOM, LYNN M (PA-C)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:M
Last Name:VANTHOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:M
Other - Last Name:VANDEHEY THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10670 NE CORNELL RD STE 300
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9221
Practice Address - Country:US
Practice Address - Phone:503-216-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01316363A00000X
CA18232363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR169773Medicare PIN