Provider Demographics
NPI:1689778979
Name:KEN P LEE MD PLLC
Entity Type:Organization
Organization Name:KEN P LEE MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-705-3061
Mailing Address - Street 1:PO BOX 11009
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-1009
Mailing Address - Country:US
Mailing Address - Phone:360-352-2037
Mailing Address - Fax:360-352-0637
Practice Address - Street 1:2740 PACIFIC AVE SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501
Practice Address - Country:US
Practice Address - Phone:360-705-3061
Practice Address - Fax:360-705-2965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD34440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1100098Medicaid
WADN9936OtherRR MEDICARE PALMETTO GBA
WA0113105OtherLABOR & INDUSTRIES
WADN9936OtherRR MEDICARE PALMETTO GBA
WAGAB37091Medicare PIN