Provider Demographics
NPI:1922628320
Name:MAC, PHUONG DINH LAM (PA-C)
Entity Type:Individual
Prefix:MS
First Name:PHUONG DINH
Middle Name:LAM
Last Name:MAC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 PELHAM PKWY S BLDG 1
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1197
Mailing Address - Country:US
Mailing Address - Phone:718-918-5905
Mailing Address - Fax:
Practice Address - Street 1:1400 PELHAM PKWY S RM 5
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1197
Practice Address - Country:US
Practice Address - Phone:817-918-5905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-26
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY025706207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program