Provider Demographics
NPI:1609361641
Name:LINCOLN, JAY DEAN
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:DEAN
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 1:100 MAIN STREET
Mailing Address - Street 2:APT 202
Mailing Address - City:PAGO PAGO
Mailing Address - State:AS
Mailing Address - Zip Code:96799-5666
Mailing Address - Country:US
Mailing Address - Phone:684-699-6380
Mailing Address - Fax:684-699-6374
Practice Address - Street 1:100 MAIN STREET
Practice Address - Street 2:APT 202
Practice Address - City:PAGO PAGO
Practice Address - State:AS
Practice Address - Zip Code:96799-5666
Practice Address - Country:US
Practice Address - Phone:684-699-6380
Practice Address - Fax:684-699-6374
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2023-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AS4105C207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine