Provider Demographics
NPI:1114965332
Name:LEE, JASON KWANG-GU (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:KWANG-GU
Last Name:LEE
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:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:801 BROADWAY
Practice Address - Street 2:SUITE 500
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4396
Practice Address - Country:US
Practice Address - Phone:206-682-6087
Practice Address - Fax:206-343-7190
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000463822086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8452575Medicaid
WAH06109Medicare UPIN
WA8452575Medicaid