=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053986117
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE YOON-JI LEE PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2021
-----------------------------------------------------
Last Update Date | 04/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17051 SIERRA LAKES PKWY STE 101
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92336-1274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-864-4700
-----------------------------------------------------
Fax | 909-428-2191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 DATA DR
-----------------------------------------------------
City | RANCHO CORDOVA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95670-7956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------