Provider Demographics
NPI:1528166550
Name:LAM, BETHANY K (PA)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:K
Last Name:LAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BINH
Other - Middle Name:K
Other - Last Name:LY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1133
Mailing Address - Country:US
Mailing Address - Phone:321-841-5560
Mailing Address - Fax:407-425-5947
Practice Address - Street 1:21 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1133
Practice Address - Country:US
Practice Address - Phone:321-841-5560
Practice Address - Fax:407-425-5947
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103894363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292662800Medicaid
FL292662800Medicaid
FLAB104XMedicare PIN
Q75825Medicare UPIN