Basic Information
Provider Information | |||||||||
NPI: | 1942216296 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEE | ||||||||
FirstName: | NANCY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEE | ||||||||
OtherFirstName: | NANCY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 12221 N. MOPAC EXPRESSWAY | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787582483 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5129014011 | ||||||||
FaxNumber: | 5129013911 | ||||||||
Practice Location | |||||||||
Address1: | 12221 N. MOPAC EXPRESSWAY | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787582483 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5129014011 | ||||||||
FaxNumber: | 5129013911 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2006 | ||||||||
LastUpdateDate: | 03/17/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00018 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 186837401 | 05 | TX |   | MEDICAID |