Provider Demographics
NPI:1790042083
Name:LEE, DEREK (CNMT, PET)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:CNMT, PET
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28322 N 223RD LN
Mailing Address - Street 2:
Mailing Address - City:WITTMANN
Mailing Address - State:AZ
Mailing Address - Zip Code:85361-8780
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28322 N 223RD LN
Practice Address - Street 2:
Practice Address - City:WITTMANN
Practice Address - State:AZ
Practice Address - Zip Code:85361-8780
Practice Address - Country:US
Practice Address - Phone:623-388-2909
Practice Address - Fax:623-388-2909
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCNMT-004042471N0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine Technology