Provider Demographics
NPI:1407406143
Name:LEE, PENG
Entity Type:Individual
Prefix:
First Name:PENG
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 1:190 MAIN ST APT C
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-1566
Mailing Address - Country:US
Mailing Address - Phone:971-325-0792
Mailing Address - Fax:
Practice Address - Street 1:190 MAIN ST APT C
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-1566
Practice Address - Country:US
Practice Address - Phone:971-325-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-15
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
052519CH00009070OtherOVERSEA MEDICAL INSURANCE