Provider Demographics
NPI:1740353432
Name:LEE, EVAN W JR (DO)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:W
Last Name:LEE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 W ESCALANTE DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4470
Mailing Address - Country:US
Mailing Address - Phone:808-651-8846
Mailing Address - Fax:
Practice Address - Street 1:645 E 5TH ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2202
Practice Address - Country:US
Practice Address - Phone:208-549-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-997207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI111156OtherUHA
HI538332 01Medicaid
HI0000242321OtherHMSA
HI111156OtherUHA
HI538332 01Medicaid