Provider Demographics
NPI:1013303528
Name:LEE, MIKKO
Entity Type:Individual
Prefix:
First Name:MIKKO
Middle Name:
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 1:4415 SHEPARD RD NE
Mailing Address - Street 2:15-2I
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1831
Mailing Address - Country:US
Mailing Address - Phone:505-236-9538
Mailing Address - Fax:
Practice Address - Street 1:4415 SHEPARD RD NE
Practice Address - Street 2:15-2I
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1831
Practice Address - Country:US
Practice Address - Phone:505-236-9538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer