Basic Information
| Provider Information | |||||||||
| NPI: | 1821600057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | KA WING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 154 ELM REED AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891482841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263489193 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6671 LAS VEGAS BLVD S UNIT 210 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891193289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104061500 | ||||||||
| FaxNumber: | 3104061531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2020 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y | 193400000X SINGLE SPECIALTY GROUP |
ID Information
| ID | Type | State | Issuer | Description | BACB585126 | 01 | NV | RBT PARAPROFESSIONAL | OTHER |