Provider Demographics
NPI:1194833111
Name:LEE, MYRNA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MYRNA
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 1:1740 E 17TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6375
Mailing Address - Country:US
Mailing Address - Phone:208-346-7500
Mailing Address - Fax:208-346-7501
Practice Address - Street 1:1740 E 17TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6375
Practice Address - Country:US
Practice Address - Phone:208-346-7500
Practice Address - Fax:208-346-7501
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA334363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806327800Medicaid
ID806327800Medicaid