Healthcare Provider Details

I. General information

NPI: 1063379543
Provider Name (Legal Business Name): JOSEPH YAE-DAM LEE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 TOWN CENTER DR STE 405
RESTON VA
20190-3218
US

IV. Provider business mailing address

1830 TOWN CENTER DR STE 405
RESTON VA
20190-3218
US

V. Phone/Fax

Practice location:
  • Phone: 703-481-9191
  • Fax:
Mailing address:
  • Phone: 703-481-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110011941
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: