Basic Information
| Provider Information | |||||||||
| NPI: | 1215285382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | GABERIEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636 | ||||||||
| Address2: | |||||||||
| City: | NEWBERG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971320636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035384874 | ||||||||
| FaxNumber: | 5035381271 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | NEWBERG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971322909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035384874 | ||||||||
| FaxNumber: | 5035381271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2012 | ||||||||
| LastUpdateDate: | 08/21/2012 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 500625268 | 05 | OR | MEDICAID |