Provider Demographics
NPI:1043990104
Name:LAM, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:LAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19515 SALADO CREEK CT
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-3968
Mailing Address - Country:US
Mailing Address - Phone:832-420-5735
Mailing Address - Fax:
Practice Address - Street 1:3450 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3300
Practice Address - Country:US
Practice Address - Phone:979-209-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer