Provider Demographics
NPI:1528016441
Name:LUM, JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LUM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JON
Other - Middle Name:
Other - Last Name:LUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1389 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3104
Mailing Address - Country:US
Mailing Address - Phone:203-755-5555
Mailing Address - Fax:203-573-8523
Practice Address - Street 1:1389 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3104
Practice Address - Country:US
Practice Address - Phone:203-755-5555
Practice Address - Fax:203-573-8523
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000669363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004085636Medicaid
P42407Medicare UPIN
CT004085636Medicaid