Basic Information
| Provider Information | |||||||||
| NPI: | 1902863301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYNCH | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | CARRADINE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX DD | ||||||||
| Address2: | |||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875712199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057588883 | ||||||||
| FaxNumber: | 5057515718 | ||||||||
| Practice Location | |||||||||
| Address1: | 1397 WEIMER RD | ||||||||
| Address2: | |||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875712199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057588883 | ||||||||
| FaxNumber: | 5057515705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/17/2007 | ||||||||
| NPIReactivationDate: | 08/21/2007 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 93-84 | NM | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 19748 | 05 | NM | MEDICAID |