Healthcare Provider Details

I. General information

NPI: 1649378399
Provider Name (Legal Business Name): LINCOLN OLALEKAN ADEYEMI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82-68 164TH ST
JAMAICA NY
11432-1121
US

IV. Provider business mailing address

506 LENOX AVENUE
NEW YORK NY
10037
US

V. Phone/Fax

Practice location:
  • Phone: 718-883-3225
  • Fax: 718-883-6193
Mailing address:
  • Phone: 718-873-7195
  • Fax: 212-939-8409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number010990
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: