Healthcare Provider Details

I. General information

NPI: 1073635058
Provider Name (Legal Business Name): REBEKAH M LEE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBEKAH M LEE MHA, MBA, FACHE

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 W FORT ST FL 2
BOISE ID
83702-4535
US

IV. Provider business mailing address

444 W FORT ST FL 2
BOISE ID
83702-4535
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1018
  • Fax:
Mailing address:
  • Phone: 208-422-1018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12474196-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12474196-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: