Provider Demographics
NPI:1578242301
Name:LAKE, ADAM
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:LAKE
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 1:9070 STATE ROUTE 5 AND 20
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14469-9407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9070 STATE ROUTE 5 AND 20
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NY
Practice Address - Zip Code:14469-9407
Practice Address - Country:US
Practice Address - Phone:585-331-3160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant