Provider Demographics
NPI:1831258367
Name:FONSECA, LEE MICHAEL (NP-C)
Entity type:Individual
Prefix:MR
First Name:LEE
Middle Name:MICHAEL
Last Name:FONSECA
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 800022 SUITE 37
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-0022
Mailing Address - Country:US
Mailing Address - Phone:800-953-0103
Mailing Address - Fax:303-765-6670
Practice Address - Street 1:4112 OUTLOOK BLVD
Practice Address - Street 2:SUITE 37
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1667
Practice Address - Country:US
Practice Address - Phone:719-562-6254
Practice Address - Fax:719-562-6255
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO105831363LF0000X
COAPN.0004081-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92354378Medicaid
COQ39857Medicare UPIN
CO92354378Medicaid