Provider Demographics
NPI:1053698514
Name:LAM, LILY FONG (PT)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:FONG
Last Name:LAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20996 REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5918
Mailing Address - Country:US
Mailing Address - Phone:510-537-0272
Mailing Address - Fax:
Practice Address - Street 1:20996 REDWOOD RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5918
Practice Address - Country:US
Practice Address - Phone:510-537-0272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-12
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT38269225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA117256Medicare PIN
CAZZZ06873ZMedicare PIN
CACA117257Medicare PIN
CACP932Medicare PIN