Provider Demographics
NPI:1851168363
Name:LEE, ISAAC JISUNG
Entity Type:Individual
Prefix:DR
First Name:ISAAC
Middle Name:JISUNG
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11904 SW VIEWCREST CT
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-2573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:583 COMMERCE DRIVE
Practice Address - Street 2:
Practice Address - City:SMELTERVILLE
Practice Address - State:ID
Practice Address - Zip Code:83868
Practice Address - Country:US
Practice Address - Phone:208-783-2739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP10253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist