Basic Information
| Provider Information | |||||||||
| NPI: | 1205149853 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACQUAVIVA | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | WEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 829641 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191821754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2673705285 | ||||||||
| FaxNumber: | 2152303725 | ||||||||
| Practice Location | |||||||||
| Address1: | 4897 YORK RD | ||||||||
| Address2: | |||||||||
| City: | BUCKINGHAM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157947471 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2010 | ||||||||
| LastUpdateDate: | 01/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OT013714 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS016279 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1028580420002 | 05 | PA | MEDICAID |