Provider Demographics
NPI:1700921590
Name:LEE, YO SUP (CRNA)
Entity Type:Individual
Prefix:
First Name:YO
Middle Name:SUP
Last Name:LEE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 S SERVICE RD
Mailing Address - Street 2:STE 350
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2358
Mailing Address - Country:US
Mailing Address - Phone:516-945-3000
Mailing Address - Fax:516-985-3131
Practice Address - Street 1:2501 PARKERS LANE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3209
Practice Address - Country:US
Practice Address - Phone:703-664-7048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001186693367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD416240401Medicaid
VA1700921590Medicaid
DC03213F89Medicare PIN
DC132526ZAJWMedicare PIN