Basic Information
| Provider Information | |||||||||
| NPI: | 1801823851 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | HISOON | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNA ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2441 STAVER ST | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339805914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2398100313 | ||||||||
| FaxNumber: | 9418759363 | ||||||||
| Practice Location | |||||||||
| Address1: | 21298 OLEAN BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339526705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416291181 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | ARNP1654692 | FL | N | Nursing Service Providers | Registered Nurse | 367500000X | RN1654692 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 304661300 | 05 | FL | MEDICAID | 1654692 | 01 | ARNP | OTHER |