Provider Demographics
NPI:1881086874
Name:LEE, CHEOL WOONG
Entity type:Individual
Prefix:
First Name:CHEOL WOONG
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 1:47 BALL PARK LN
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-4501
Mailing Address - Country:US
Mailing Address - Phone:646-236-8847
Mailing Address - Fax:516-934-0246
Practice Address - Street 1:47 BALL PARK LN
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-4501
Practice Address - Country:US
Practice Address - Phone:646-236-8847
Practice Address - Fax:516-934-0246
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339369363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04100538Medicaid
A400121324Medicare PIN