Provider Demographics
NPI:1962437400
Name:SQUANDA, LYNN MARIE (DO)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:MARIE
Last Name:SQUANDA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:MARIE
Other - Last Name:SQUANDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:524 S COURT AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1215
Mailing Address - Country:US
Mailing Address - Phone:989-350-4105
Mailing Address - Fax:
Practice Address - Street 1:1140 N STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT IGNACE
Practice Address - State:MI
Practice Address - Zip Code:49781-1048
Practice Address - Country:US
Practice Address - Phone:906-643-8689
Practice Address - Fax:906-643-4165
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013512207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4547432Medicaid
MI0156910035OtherBCBSM PROVIDER NUMBER
381303843OtherTAX ID
CC4805OtherMEDICARE RR PROV ID
11289516OtherCAQH PROVIDER ID
MI4547432Medicaid
G80457Medicare UPIN