Basic Information
| Provider Information | |||||||||
| NPI: | 1003070780 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLYNN | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLYNN | ||||||||
| OtherFirstName: | JERALD | ||||||||
| OtherMiddleName: | PAUL | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2816 | ||||||||
| Address2: | |||||||||
| City: | SEWARD | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996642816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074910645 | ||||||||
| FaxNumber: | 8887231672 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | SEWARD | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996640365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072245205 | ||||||||
| FaxNumber: | 9072247428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2008 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | LL17668 | OR | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 7109 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 52680 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 96608226 | 05 | CO | MEDICAID | MD9543 | 05 | AK | MEDICAID |