Provider Demographics
NPI:1184913022
Name:LAM, BRIAN (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:LAM
Suffix:
Gender:M
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:PO BOX 1000
Mailing Address - Street 2:DEPT # 457
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-486-8811
Mailing Address - Fax:
Practice Address - Street 1:1211 UNION AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-6638
Practice Address - Country:US
Practice Address - Phone:901-609-3520
Practice Address - Fax:901-266-6451
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1958363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1525080Medicaid
TN6016537OtherBCBS
MS05932552Medicaid
MS05932552Medicaid