Provider Demographics
NPI:1609864545
Name:LEE, TINA JISUN (MD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:JISUN
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JISUN
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:747 BROADWAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4379
Practice Address - Country:US
Practice Address - Phone:206-215-2520
Practice Address - Fax:206-386-3180
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4275207Q00000X
PAMD443886207Q00000X
WAMD61059119207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2242000Medicaid
TX187046101Medicaid
PA002670002OtherHIGHMARK BCBS
PA1609864545OtherUNITED HEALTHCARE
PA48791369OtherCIGNA
PA1609864545OtherUNITED HEALTHCARE
TX187046101Medicaid