Basic Information
| Provider Information | |||||||||
| NPI: | 1598298275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAXA | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142192000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 945 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532331305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142192000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2017 | ||||||||
| LastUpdateDate: | 01/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036152515 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 76087 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100181894 | 05 | WI | MEDICAID |