Provider Demographics
NPI:1508881574
Name:LEE, JAY PUN (PA-C)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:PUN
Last Name:LEE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:PUN
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:23785 EL TORO RD
Mailing Address - Street 2:SUITE 609
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4762
Mailing Address - Country:US
Mailing Address - Phone:818-349-9966
Mailing Address - Fax:818-349-5615
Practice Address - Street 1:23785 EL TORO RD
Practice Address - Street 2:SUITE 609
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4762
Practice Address - Country:US
Practice Address - Phone:818-349-9966
Practice Address - Fax:818-349-5615
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15457363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15457Medicaid
CAPA15457Medicaid
CAPA15457Medicaid