Provider Demographics
NPI:1215281696
Name:LINCOLN, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:LINCOLN
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 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1610 MEDICAL DR
Practice Address - Street 2:SUITE 105
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464-3292
Practice Address - Country:US
Practice Address - Phone:484-945-0405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP012493363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health