MEDICARE: AETHERUS WOUND AND LYMPHATICS PLLC

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	163WW0000X	Wound Care Registered Nurse
2	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1770413445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AETHERUS WOUND AND LYMPHATICS PLLC

Provider Business Mailing Address
First Line	:	15303 AMBERLY DR STE C
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-2308
Country	:	US
Telephone Number	:	813-212-6517
Fax Number	:	813-212-6518

Provider Business Practice Location Address
First Line	:	15310 AMBERLY DR STE 195
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-1646
Country	:	US
Telephone Number	:	813-212-6517
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LOAN LAM
Credential	:	MD
Telephone Number	:	813-212-6517

Provider Enumeration Date	:	05/22/2026
Last Update Date	:	06/23/2026

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