Provider Demographics
NPI:1598037152
Name:LEE, LAURA (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 S ALMA SCHOOL RD STE 354
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3028
Mailing Address - Country:US
Mailing Address - Phone:480-726-2287
Mailing Address - Fax:888-316-9272
Practice Address - Street 1:601 W TERRELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3243
Practice Address - Country:US
Practice Address - Phone:817-702-3100
Practice Address - Fax:817-702-4847
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-29
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7034950001332B00000X
AZ7047150001332B00000X
AZ7629170001332B00000X
AZ7046960001332B00000X
AZ7045160001332B00000X
AZ7057360001332B00000X
AZ7209350001332B00000X
AZ5018363A00000X
363A00000X
TXPA15143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies