Provider Demographics
NPI:1831533231
Name:LEE, BRIAN EUGENE
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:EUGENE
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 1:2020 PALOMINO LN STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4894
Mailing Address - Country:US
Mailing Address - Phone:702-759-8600
Mailing Address - Fax:702-384-1815
Practice Address - Street 1:2020 PALOMINO LN STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4894
Practice Address - Country:US
Practice Address - Phone:702-759-8600
Practice Address - Fax:702-384-1815
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
NV189342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1831533231Medicaid