Provider Demographics
NPI:1710755673
Name:LEE, EUNICE PONG (PA)
Entity Type:Individual
Prefix:
First Name:EUNICE
Middle Name:PONG
Last Name:LEE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 DURALEIGH RD STE 205
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-8105
Mailing Address - Country:US
Mailing Address - Phone:919-784-7874
Mailing Address - Fax:
Practice Address - Street 1:3100 DURALEIGH RD STE 205
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8105
Practice Address - Country:US
Practice Address - Phone:919-784-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant