=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013752096
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAEHO JOSHUA LEE PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2024
-----------------------------------------------------
Last Update Date | 07/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 4TH ST
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-290-5100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2253 DAISY LN
-----------------------------------------------------
City | LA CANADA FLINTRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91011-1412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA66825
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------