Provider Demographics
NPI:1720472939
Name:LEE, KRYSTAL
Entity Type:Individual
Prefix:
First Name:KRYSTAL
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 1:47 NEW SCOTLAND AVE
Mailing Address - Street 2:DEPTARTMENT OF GENERAL SURGERY
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3412
Mailing Address - Country:US
Mailing Address - Phone:518-262-5374
Mailing Address - Fax:
Practice Address - Street 1:301 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8408
Practice Address - Country:US
Practice Address - Phone:631-968-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY723729709390200000X
NY323981208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program