Provider Demographics
NPI:1629096102
Name:LEE, CONAN H (PT)
Entity Type:Individual
Prefix:
First Name:CONAN
Middle Name:H
Last Name:LEE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1784 GRAIN MILL RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-1090
Mailing Address - Country:US
Mailing Address - Phone:760-891-0601
Mailing Address - Fax:760-798-4545
Practice Address - Street 1:1784 GRAIN MILL RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-1090
Practice Address - Country:US
Practice Address - Phone:858-361-5599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2012-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23843225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPT23843BOtherPPIN
W15730AMedicare ID - Type Unspecified