Basic Information
| Provider Information | |||||||||
| NPI: | 1518522648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYNCH | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43667 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322033667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047200599 | ||||||||
| FaxNumber: | 9043764036 | ||||||||
| Practice Location | |||||||||
| Address1: | 836 PRUDENTIAL DR STE 1700 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043980125 | ||||||||
| FaxNumber: | 9043981832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2019 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9112507 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.