Provider Demographics
NPI:1093747479
Name:YANG, LEE (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:YANG
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:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-0589
Mailing Address - Country:US
Mailing Address - Phone:218-290-5997
Mailing Address - Fax:
Practice Address - Street 1:1421 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2240
Practice Address - Country:US
Practice Address - Phone:218-290-5997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37572208600000X
CAG78231208600000X
NY189116208600000X
NMMD2014-0794208600000X
KS04-35291208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN830518800Medicaid
MN020002099Medicare ID - Type Unspecified
MN830518800Medicaid