Provider Demographics
NPI:1073608550
Name:LEE, KATHERINE BO (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:BO
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5870 N HIATUS RD., STE. 200
Mailing Address - Street 2:TEAMHEALTH PROVIDER ENROLLMENT
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-6424
Mailing Address - Country:US
Mailing Address - Phone:505-858-1222
Mailing Address - Fax:818-861-3324
Practice Address - Street 1:10101 LAGRIMA DE ORO NE
Practice Address - Street 2:CANYON TRANSITIONAL HEALTHCARE & REHAB
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111
Practice Address - Country:US
Practice Address - Phone:505-858-1222
Practice Address - Fax:818-861-3324
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261221207R00000X
OH35065385L207R00000X
NMMD2015-0912207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0959833Medicaid
OH0959833Medicaid