Healthcare Provider Details

I. General information

NPI: 1063244176
Provider Name (Legal Business Name): NICHOLAS G LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOSTON MEDICAL CTR PL STE 1
BOSTON MA
02118-2999
US

IV. Provider business mailing address

1 BOSTON MEDICAL CTR PL STE 1
BOSTON MA
02118-2999
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-5481
  • Fax:
Mailing address:
  • Phone: 508-380-3849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA102515
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: