Provider Demographics
NPI:1568847762
Name:LEE, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 MOUNTAIN VISTA ST
Mailing Address - Street 2:APT 1421
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-2161
Mailing Address - Country:US
Mailing Address - Phone:510-754-9611
Mailing Address - Fax:
Practice Address - Street 1:5400 MOUNTAIN VISTA ST
Practice Address - Street 2:APT 1421
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-2161
Practice Address - Country:US
Practice Address - Phone:510-754-9611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
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
NV00001994561Medicaid