Basic Information
| Provider Information | |||||||||
| NPI: | 1962437400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SQUANDA | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SQUANDA | ||||||||
| OtherFirstName: | LYNN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3215 DAWN DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486424092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893504105 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1523 S MISSION ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488584230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897731166 | ||||||||
| FaxNumber: | 9897726835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101013512 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 381303843 | 01 | TAX ID | OTHER | 11289516 | 01 | CAQH PROVIDER ID | OTHER | CC4805 | 01 | MEDICARE RR PROV ID | OTHER | 4547432 | 05 | MI | MEDICAID | 0156910035 | 01 | MI | BCBSM PROVIDER NUMBER | OTHER |