Provider Demographics
NPI:1093280604
Name:LEE, JULIA (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 20TH ST STE 280
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2053
Mailing Address - Country:US
Mailing Address - Phone:310-829-6789
Mailing Address - Fax:
Practice Address - Street 1:1301 20TH ST STE 280
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2053
Practice Address - Country:US
Practice Address - Phone:310-829-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13387363A00000X
CA60813363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX411313601Medicaid
TX411313602OtherCSHCN TPI