Healthcare Provider Details

I. General information

NPI: 1194833111
Provider Name (Legal Business Name): MYRNA LEE P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 E 17TH ST SUITE A
IDAHO FALLS ID
83404-6375
US

IV. Provider business mailing address

1740 E 17TH ST SUITE A
IDAHO FALLS ID
83404-6375
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax: 208-346-7501
Mailing address:
  • Phone: 208-346-7500
  • Fax: 208-346-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA334
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: