Healthcare Provider Details

I. General information

NPI: 1790610517
Provider Name (Legal Business Name): RYAN JOHN LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

718 RILL DR
AUGUSTA GA
30909-1985
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-6045
  • Fax:
Mailing address:
  • Phone: 678-530-5168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: