Provider Demographics
NPI:1700138575
Name:LEE, WON JAE (ATC)
Entity Type:Individual
Prefix:
First Name:WON JAE
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21212 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2033
Mailing Address - Country:US
Mailing Address - Phone:718-224-0844
Mailing Address - Fax:718-224-6684
Practice Address - Street 1:21212 41ST AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2033
Practice Address - Country:US
Practice Address - Phone:714-224-0844
Practice Address - Fax:718-224-6684
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT54152255A2300X
NY0024702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer