Provider Demographics
NPI:1235532623
Name:LEE, BENNETT H (PA-C)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:H
Last Name:LEE
Suffix:
Gender:M
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 1:1097 GREAT OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1016
Mailing Address - Country:US
Mailing Address - Phone:248-752-6886
Mailing Address - Fax:
Practice Address - Street 1:1460 WALTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1768
Practice Address - Country:US
Practice Address - Phone:248-650-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007108363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical