Healthcare Provider Details

I. General information

NPI: 1295085157
Provider Name (Legal Business Name): MICHAEL J. LEE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MORA VALLEY CLINIC RD
MORA NM
87732-2202
US

IV. Provider business mailing address

PO BOX 209
MORA NM
87732-0209
US

V. Phone/Fax

Practice location:
  • Phone: 877-271-2201
  • Fax: 575-387-9006
Mailing address:
  • Phone: 877-271-2201
  • Fax: 505-387-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2012-0040
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: