Basic Information
Provider Information | |||||||||
NPI: | 1124262233 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LYN | ||||||||
FirstName: | ANDRIA | ||||||||
MiddleName: | DIAN | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LYN-GARDINER | ||||||||
OtherFirstName: | ANDRIA | ||||||||
OtherMiddleName: | DIAN | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 68 S SERVICE RD | ||||||||
Address2: | SUITE 350 | ||||||||
City: | MELVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 117472354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5169453156 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 COMMUNITY DR | ||||||||
Address2: | DEPT OF ANESTHESIA | ||||||||
City: | MANHASSET | ||||||||
State: | NY | ||||||||
PostalCode: | 110303816 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5165624887 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2009 | ||||||||
LastUpdateDate: | 01/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 445958 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.