Basic Information
| Provider Information | |||||||||
| NPI: | 1972928778 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JUSTIN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 410272 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641410272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132341350 | ||||||||
| FaxNumber: | 9132341108 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 MARSHALL ST | ||||||||
| Address2: | |||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660483235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136841100 | ||||||||
| FaxNumber: | 9136841239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2014 | ||||||||
| LastUpdateDate: | 06/19/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 13072095072 | KS | N | Nursing Service Providers | Registered Nurse | 367500000X | 557247 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.