Provider Demographics
NPI:1790321495
Name:LEE, KENG
Entity type:Individual
Prefix:
First Name:KENG
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 EDINBROOK TER
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3908
Mailing Address - Country:US
Mailing Address - Phone:715-492-0763
Mailing Address - Fax:
Practice Address - Street 1:4625 EDINBROOK TER
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3908
Practice Address - Country:US
Practice Address - Phone:715-492-0763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2024-06-17
Deactivation Date:2019-11-18
Deactivation Code:
Reactivation Date:2024-06-17
Provider Licenses
StateLicense IDTaxonomies
MNA2458225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant