Provider Demographics
NPI:1467993006
Name:LEE, SUN (PTA)
Entity Type:Individual
Prefix:
First Name:SUN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 FOLSOM ST APT 185
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-6821
Mailing Address - Country:US
Mailing Address - Phone:217-714-6195
Mailing Address - Fax:
Practice Address - Street 1:205 S MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1716
Practice Address - Country:US
Practice Address - Phone:303-702-1612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0013592225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant