Healthcare Provider Details

I. General information

NPI: 1710302724
Provider Name (Legal Business Name): LEE XIONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2014
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

892 SIMS AVE
SAINT PAUL MN
55106-3828
US

IV. Provider business mailing address

892 SIMS AVE
SAINT PAUL MN
55106
UM

V. Phone/Fax

Practice location:
  • Phone: 651-605-1174
  • Fax:
Mailing address:
  • Phone: 651-605-1147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberK80114019209
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: