Provider Demographics
NPI:1740462233
Name:LEE, KEN P (MD)
Entity type:Individual
Prefix:DR
First Name:KEN
Middle Name:P
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 PACIFIC AVE SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-2037
Mailing Address - Country:US
Mailing Address - Phone:360-705-3061
Mailing Address - Fax:
Practice Address - Street 1:2740 PACIFIC AVE SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2037
Practice Address - Country:US
Practice Address - Phone:360-705-3061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2012-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD34440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00650748OtherRR MEDICARE PALMETTO GBA
WA0113105OtherLABOR & INDUSTRIES
WALE4906OtherREGENCE BLUESHIELD
WAGAB37092Medicare PIN
WAF86873Medicare UPIN