MEDICARE: ETHAN LAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1295599801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHAN LAM

Provider Business Mailing Address
First Line	:	5 MOUNTAIN ROSE CT
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-4869
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	114 GATEWAY CORPORATE BLVD STE 210
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-9785
Country	:	US
Telephone Number	:	803-365-8640
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2024
Last Update Date	:	12/15/2025

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Directions to “ ETHAN LAM ” Practice Location

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