Provider Demographics
NPI:1396255253
Name:LAM, JONATHAN WEI
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:WEI
Last Name:LAM
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 1:21003 AMIE AVE
Mailing Address - Street 2:37
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4744
Mailing Address - Country:US
Mailing Address - Phone:424-394-9728
Mailing Address - Fax:
Practice Address - Street 1:390 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4475
Practice Address - Country:US
Practice Address - Phone:310-640-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47911225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty