Provider Demographics
NPI:1790772622
Name:PACE, LEE WENDEL (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:WENDEL
Last Name:PACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 N GILBERT RD
Mailing Address - Street 2:SUITE 2 PMB 188
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-5136
Mailing Address - Country:US
Mailing Address - Phone:480-868-9650
Mailing Address - Fax:480-834-3606
Practice Address - Street 1:1106 N GILBERT RD
Practice Address - Street 2:SUITE 2 PMB 188
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-5136
Practice Address - Country:US
Practice Address - Phone:480-868-9650
Practice Address - Fax:480-834-3606
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12301208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ212770Medicaid
D37405Medicare UPIN
AZZ126032Medicare PIN
AZ212770Medicaid