Provider Demographics
NPI:1386792612
Name:GROSS, LYNN M (PA)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:M
Last Name:GROSS
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 1:209 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4265
Mailing Address - Country:US
Mailing Address - Phone:253-596-3300
Mailing Address - Fax:253-596-3301
Practice Address - Street 1:209 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4265
Practice Address - Country:US
Practice Address - Phone:253-596-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003889363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8363327Medicaid
WA8363327Medicaid
WAG8804077Medicare PIN
WAG8804075Medicare PIN
WAG8804081Medicare PIN
WAG8804079Medicare PIN
WAGAB25549Medicare PIN
WAG8872352Medicare PIN
WAP00353608Medicare PIN