Healthcare Provider Details

I. General information

NPI: 1073820536
Provider Name (Legal Business Name): LAUREN MICHELLE LEE RPAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2010
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 KINGSBURY GRADE STE 101
STATELINE NV
89449-9804
US

IV. Provider business mailing address

PO BOX 5910
STATELINE NV
89449-5910
US

V. Phone/Fax

Practice location:
  • Phone: 775-588-5000
  • Fax:
Mailing address:
  • Phone: 775-588-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number014203
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: