Basic Information
Provider Information | |||||||||
NPI: | 1295142149 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEE | ||||||||
FirstName: | KYUNG WOON | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 37491 ENTERPRISE DR | ||||||||
Address2: |   | ||||||||
City: | BURNEY | ||||||||
State: | CA | ||||||||
PostalCode: | 960134379 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5309999030 | ||||||||
FaxNumber: | 5303353060 | ||||||||
Practice Location | |||||||||
Address1: | 37491 ENTERPRISE DR | ||||||||
Address2: |   | ||||||||
City: | BURNEY | ||||||||
State: | CA | ||||||||
PostalCode: | 960134379 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5309999030 | ||||||||
FaxNumber: | 5303353060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2014 | ||||||||
LastUpdateDate: | 08/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN211429 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | RN211429 | 01 | GA | GEORGIA LICENSE | OTHER |