Healthcare Provider Details

I. General information

NPI: 1164316444
Provider Name (Legal Business Name): VICKI LIN PA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GRAND CONCOURSE
BRONX NY
10457-7679
US

IV. Provider business mailing address

1276 FULTON AVE
BRONX NY
10456-3467
US

V. Phone/Fax

Practice location:
  • Phone: 718-992-7669
  • Fax:
Mailing address:
  • Phone: 718-992-7669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number034377
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: