Provider Demographics
NPI:1750958161
Name:LAI, AMY DIEM
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:DIEM
Last Name:LAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 CIMMARON AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1308
Mailing Address - Country:US
Mailing Address - Phone:805-813-4277
Mailing Address - Fax:
Practice Address - Street 1:4005 MISSION OAKS BLVD STE A
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-5156
Practice Address - Country:US
Practice Address - Phone:805-484-7921
Practice Address - Fax:805-983-4186
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-06
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant