Provider Demographics
NPI:1164612131
Name:LEE, NATHAN RYAN (CPO)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:RYAN
Last Name:LEE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 E CHAPMAN AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-3850
Mailing Address - Country:US
Mailing Address - Phone:714-626-0417
Mailing Address - Fax:714-626-0319
Practice Address - Street 1:810 E CHAPMAN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3850
Practice Address - Country:US
Practice Address - Phone:714-626-0417
Practice Address - Fax:714-626-0319
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CPO 02709335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0027090OtherMEDI-CAL RENDERING