Basic Information
| Provider Information | |||||||||
| NPI: | 1609852177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | SUSANNE | ||||||||
| MiddleName: | NUSSEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 3805 W CHESTER PIKE BLDG D | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | NEWTOWN SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190732329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002570117 | ||||||||
| FaxNumber: | 6105503079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZD0900X | C1-0008614 | DE | N | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZP0102X | MD421782 | PA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZD0900X | MD421782 | PA | Y | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 11517014 | 01 | CAQH | OTHER |