Healthcare Provider Details

I. General information

NPI: 1982328506
Provider Name (Legal Business Name): JUNG IN LEE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3255 WILSHIRE BLVD STE 120
LOS ANGELES CA
90010-1405
US

IV. Provider business mailing address

3727 W 6TH ST STE 210
LOS ANGELES CA
90020-5108
US

V. Phone/Fax

Practice location:
  • Phone: 213-235-2500
  • Fax: 213-355-8714
Mailing address:
  • Phone: 213-235-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA63849
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: