Basic Information
| Provider Information | |||||||||
| NPI: | 1033432604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | Y | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 SAN PABLO AVE | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947061103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102048130 | ||||||||
| FaxNumber: | 5105240861 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 SAN PABLO AVE | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947061103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102048130 | ||||||||
| FaxNumber: | 5105240861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2010 | ||||||||
| LastUpdateDate: | 02/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA20598 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.