Healthcare Provider Details

I. General information

NPI: 1881519882
Provider Name (Legal Business Name): NATHAN GORDON LEE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 WILSHIRE BLVD
SANTA MONICA CA
90401-1409
US

IV. Provider business mailing address

427 WILSHIRE BLVD
SANTA MONICA CA
90401-1409
US

V. Phone/Fax

Practice location:
  • Phone: 310-656-8600
  • Fax: 310-656-8606
Mailing address:
  • Phone: 310-656-8600
  • Fax: 310-656-8606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number54979
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: