Provider Demographics
NPI:1275156184
Name:LEE, SOO YOUNG
Entity Type:Individual
Prefix:
First Name:SOO YOUNG
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 FULTON AVE APT 2091
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-6444
Mailing Address - Country:US
Mailing Address - Phone:213-905-0544
Mailing Address - Fax:
Practice Address - Street 1:505 S VIRGIL AVE STE 205
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1443
Practice Address - Country:US
Practice Address - Phone:213-905-0544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty