Provider Demographics
NPI:1780985697
Name:LEE, SUKWOO (GNP-C, ANP-C)
Entity type:Individual
Prefix:
First Name:SUKWOO
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:GNP-C, ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 ALBANY STREET
Mailing Address - Street 2:FL G
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 MASSACHUSETTS AVENUE
Practice Address - Street 2:CROSSTOWN 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2605
Practice Address - Country:US
Practice Address - Phone:617-414-7399
Practice Address - Fax:617-414-4676
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN266179363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110088031AMedicaid
MA110088031AMedicaid