Provider Demographics
NPI:1801823851
Name:LEE, HISOON A (CRNA ARNP)
Entity type:Individual
Prefix:MRS
First Name:HISOON
Middle Name:A
Last Name:LEE
Suffix:
Gender:F
Credentials:CRNA ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 STAVER ST
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33980-5914
Mailing Address - Country:US
Mailing Address - Phone:239-810-0313
Mailing Address - Fax:941-875-9363
Practice Address - Street 1:21298 OLEAN BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6705
Practice Address - Country:US
Practice Address - Phone:941-629-1181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1654692163W00000X
FLRN1654692367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304661300Medicaid
1654692OtherARNP
FL90696Medicare PIN