Provider Demographics
NPI:1255362984
Name:LEE, PAMELA JEAN (PA)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:LEE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17369
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-7369
Mailing Address - Country:US
Mailing Address - Phone:562-424-8814
Mailing Address - Fax:562-427-2604
Practice Address - Street 1:3610 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3418
Practice Address - Country:US
Practice Address - Phone:562-424-8814
Practice Address - Fax:562-427-2604
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17020207R00000X
CAWPA17020363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA17020AMedicare ID - Type UnspecifiedMEDICARE PROVIDER