Provider Demographics
NPI:1811992696
Name:THIBODEAU, LYNN R (PA)
Entity type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:R
Last Name:THIBODEAU
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 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:4689 US HIGHWAY 17 STE 2
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4831
Practice Address - Country:US
Practice Address - Phone:904-269-6526
Practice Address - Fax:904-269-6527
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107879363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015211100Medicaid
FL015211100Medicaid
GA957933848BMedicaid
FL015211100Medicaid
GAP88100Medicare UPIN