Provider Demographics
NPI:1407057516
Name:LEE, LAURA ELLEN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:ELLEN
Last Name:LEE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1120 15TH ST
Mailing Address - Street 2:EC 3304
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-4409
Mailing Address - Fax:706-721-3990
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:EC 3304
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-4409
Practice Address - Fax:706-721-3990
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA002039363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant