Healthcare Provider Details

I. General information

NPI: 1447637392
Provider Name (Legal Business Name): DAVID CHONG HYUN LEE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DAVID CHONG HYUN LEE CRNA

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18880 BRASILIA DR
PORTER RANCH CA
91326-1950
US

IV. Provider business mailing address

538 S OAKLAND AVE APT 304
PASADENA CA
91101-4017
US

V. Phone/Fax

Practice location:
  • Phone: 808-224-0083
  • Fax:
Mailing address:
  • Phone: 808-224-0083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number839542
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number61834
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000324
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: