Provider Demographics
NPI:1649216789
Name:LEE, KRISTEN M (PA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
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 9727
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-9727
Mailing Address - Country:US
Mailing Address - Phone:309-886-9172
Mailing Address - Fax:
Practice Address - Street 1:1312 MANATEE AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1358
Practice Address - Country:US
Practice Address - Phone:941-708-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004658363AM0700X, 363A00000X
FLPA9118247363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q35450Medicare UPIN
MIP35450005Medicare PIN