Provider Demographics
NPI:1922562818
Name:TAGGART, LYNN OWEN
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:OWEN
Last Name:TAGGART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 W SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:DE
Mailing Address - Zip Code:19968-1147
Mailing Address - Country:US
Mailing Address - Phone:202-365-0920
Mailing Address - Fax:
Practice Address - Street 1:321 GENESEE ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2611
Practice Address - Country:US
Practice Address - Phone:315-363-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-007207363A00000X
AL1730363A00000X
TN4650363A00000X
390200000X
DEC5-001-1646363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program