Provider Demographics
NPI:1508474644
Name:LEE, PETER (EMT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3501
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3501
Mailing Address - Country:US
Mailing Address - Phone:503-975-8552
Mailing Address - Fax:
Practice Address - Street 1:021 SW BANCROFT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4064
Practice Address - Country:US
Practice Address - Phone:503-975-8552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR122578146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic