Healthcare Provider Details

I. General information

NPI: 1255890224
Provider Name (Legal Business Name): KEVIN KYUNGMIN LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 SIENA HEIGHTS DR STE 331
HENDERSON NV
89052-4171
US

IV. Provider business mailing address

6355 S BUFFALO DR FL 3
LAS VEGAS NV
89113-2133
US

V. Phone/Fax

Practice location:
  • Phone: 702-407-0110
  • Fax:
Mailing address:
  • Phone: 702-216-3346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number29244
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: