Provider Demographics
NPI:1871823237
Name:LEE, KAO YANG (NP-BC)
Entity Type:Individual
Prefix:
First Name:KAO
Middle Name:YANG
Last Name:LEE
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:916-585-7912
Mailing Address - Fax:877-479-7101
Practice Address - Street 1:6339 MACK RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4655
Practice Address - Country:US
Practice Address - Phone:916-585-7912
Practice Address - Fax:877-479-7101
Is Sole Proprietor?:No
Enumeration Date:2010-01-07
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20648363A00000X
CANP20882363L00000X
CA20882363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFF:8/5/13 NORWOODMedicaid
CAEFF 8/12/13-MACK RDMedicaid
CAP01453291-DV5277OtherRAILROAD MEDICARE
CAP01284201/DS9933OtherRAILROAD MEDICARE-MACK RD.
CAEFF: 8/5/13 MARYSVILMedicaid
CAEFF:8/5/13 C HEIGHTSMedicaid
CAEFF:8/5/13 55TH STMedicaid
CADE228Y-NORWOODMedicare PIN
CADE228Y-MARYSVILLEMedicare PIN
CADE228Y-MACK RDMedicare PIN
CAEFF: 8/5/13 MARYSVILMedicaid
CADE228Y-CITRUS HEIGHTMedicare PIN
CACA140761Medicare PIN