Provider Demographics
NPI:1376001925
Name:LEE, KEVIN (SRNA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8953 W MARCONI AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3731
Mailing Address - Country:US
Mailing Address - Phone:253-222-0632
Mailing Address - Fax:
Practice Address - Street 1:305 N MARTIN AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85721-0001
Practice Address - Country:US
Practice Address - Phone:520-626-6154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-03
Last Update Date:2019-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN216771367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered