Provider Demographics
NPI:1336729151
Name:LEE, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 WILSHIRE BLVD STE 530
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-5733
Mailing Address - Country:US
Mailing Address - Phone:213-483-1055
Mailing Address - Fax:213-483-1418
Practice Address - Street 1:1245 WILSHIRE BLVD STE 530
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-5733
Practice Address - Country:US
Practice Address - Phone:213-483-1055
Practice Address - Fax:213-483-1418
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59682363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant