Provider Demographics
NPI:1891251658
Name:LEE, ETHAN (DC)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:I-CHEN
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:644 FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-4812
Mailing Address - Country:US
Mailing Address - Phone:650-948-8900
Mailing Address - Fax:
Practice Address - Street 1:12330 NE 8TH ST STE 202
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3187
Practice Address - Country:US
Practice Address - Phone:425-278-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61029054111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor