Provider Demographics
NPI:1003868449
Name:WOLFE, LEE TAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:TAN
Last Name:WOLFE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19205 SIXPENNY LN
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-2852
Mailing Address - Country:US
Mailing Address - Phone:719-481-3252
Mailing Address - Fax:
Practice Address - Street 1:222 N NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907
Practice Address - Country:US
Practice Address - Phone:719-776-5142
Practice Address - Fax:719-776-5827
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18225207L00000X
CO42241207L00000X
IN01052930A207L00000X
CAA86812207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05156585Medicaid
MS05156585Medicaid