Provider Demographics
NPI:1659743623
Name:LEE, LINDA JIMI (PA-C)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:JIMI
Last Name:LEE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549TH HOSPITAL CENTER/BDAACH UNIT #15245
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96271
Mailing Address - Country:US
Mailing Address - Phone:315-737-1857
Mailing Address - Fax:
Practice Address - Street 1:549TH HOSPITAL CENTER/ BDAACH UNIT #15245
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271
Practice Address - Country:US
Practice Address - Phone:315-737-1857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006009363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1659743623Medicaid