Basic Information
Provider Information
NPI: 1003011339
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JIMENEZ
FirstName: LINCOLN
MiddleName: M
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 25608
Address2:  
City: SALT LAKE CITY
State: UT
PostalCode: 841250608
CountryCode: US
TelephoneNumber: 2063204476
FaxNumber: 2065687043
Practice Location
Address1: 500 17TH AVE
Address2:  
City: SEATTLE
State: WA
PostalCode: 981225711
CountryCode: US
TelephoneNumber: 2063202800
FaxNumber: 2063202827
Other Information
ProviderEnumerationDate: 06/18/2007
LastUpdateDate: 02/10/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 02/10/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207T00000XMD61014044WAY Allopathic & Osteopathic PhysiciansNeurological Surgery 

ID Information
IDTypeStateIssuerDescription
022573305OH MEDICAID
710047196005KY MEDICAID
100301133905WA MEDICAID


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