Basic Information
| Provider Information | |||||||||
| NPI: | 1346778644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | HOON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122108 DEPT 2108 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753120001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942921 | ||||||||
| FaxNumber: | 3374946523 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 WALTERS ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706074647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374808066 | ||||||||
| FaxNumber: | 3374808061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2017 | ||||||||
| LastUpdateDate: | 04/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 324060 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2555499 | 05 | LA | MEDICAID | 324060 | 01 | LA | STATE LICENSE | OTHER |