Provider Demographics
NPI:1992047443
Name:MORENO, LYNN M (PA-C)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:M
Last Name:MORENO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:M
Other - Last Name:LAKOMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2790 GODWIN BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8151
Mailing Address - Country:US
Mailing Address - Phone:757-983-8750
Mailing Address - Fax:757-510-9442
Practice Address - Street 1:2790 GODWIN BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8151
Practice Address - Country:US
Practice Address - Phone:757-983-8750
Practice Address - Fax:757-510-9442
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006449363A00000X
IL085004597363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical