Provider Demographics
NPI:1346790706
Name:LEE, SAMUEL JOONSANG (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:JOONSANG
Last Name:LEE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MILVIA ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-2636
Mailing Address - Country:US
Mailing Address - Phone:510-204-5600
Mailing Address - Fax:510-506-7722
Practice Address - Street 1:2500 MILVIA ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2636
Practice Address - Country:US
Practice Address - Phone:510-204-5600
Practice Address - Fax:510-506-7722
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95040295163W00000X
CA95004858207Q00000X, 363LF0000X
WAAP60798120363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner