Provider Demographics
NPI:1134529571
Name:LEE, PHILLIP BERNHARD (PA-C)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:BERNHARD
Last Name:LEE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 HILLCREST ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-1211
Mailing Address - Country:US
Mailing Address - Phone:407-425-1566
Mailing Address - Fax:407-422-0166
Practice Address - Street 1:217 HILLCREST ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-1211
Practice Address - Country:US
Practice Address - Phone:407-425-1566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05257363A00000X
363AS0400X
FLPA9108730363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIG567ZMedicare PIN