Healthcare Provider Details

I. General information

NPI: 1124964986
Provider Name (Legal Business Name): MAI DER LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4871 E KINGS CANYON RD
FRESNO CA
93727-3811
US

IV. Provider business mailing address

4855 E CESAR CHAVEZ BLVD
FRESNO CA
93727-3811
US

V. Phone/Fax

Practice location:
  • Phone: 559-390-0963
  • Fax:
Mailing address:
  • Phone: 559-390-0963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: