Provider Demographics
NPI:1558943555
Name:LEE, VIVIAN (PA)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 GENESEE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-4900
Mailing Address - Country:US
Mailing Address - Phone:858-598-6789
Mailing Address - Fax:
Practice Address - Street 1:4320 GENESEE AVE STE 103
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-4900
Practice Address - Country:US
Practice Address - Phone:858-598-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63266363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant