Provider Demographics
NPI:1144545203
Name:LINDGREN, GUENEVERE DIANNE (PA)
Entity type:Individual
Prefix:MISS
First Name:GUENEVERE
Middle Name:DIANNE
Last Name:LINDGREN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:5000 W SLAUGHTER LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749
Practice Address - Country:US
Practice Address - Phone:512-654-4000
Practice Address - Fax:512-654-4001
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07859363A00000X
TXPA-7859363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO74874349Medicaid