Basic Information
| Provider Information | |||||||||
| NPI: | 1619945508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LINDAHL | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | EDWIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LINDAHL | ||||||||
| OtherFirstName: | JOSEPH | ||||||||
| OtherMiddleName: | EDWIN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.A. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5000 CROSSINGS CIR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MT JULIET | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371228592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157581010 | ||||||||
| FaxNumber: | 6157583875 | ||||||||
| Practice Location | |||||||||
| Address1: | 5000 CROSSINGS CIR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MT JULIET | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371228592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157581010 | ||||||||
| FaxNumber: | 6157583875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0491 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | ML0575906 | 01 | DEA REGISTRATION NUMBER | OTHER | 1007128 | 01 | NCCPA NUMBER | OTHER | 3666495 | 01 | TN | MEDICARE ID | OTHER |