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General NPI Number Information
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NPI Number | 1558815522
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Entity Type | Individual
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Provider Name | JAEWON LEE CNP
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Gender | Male
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Dates
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Enumeration Date | 08/08/2016
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Last Update Date | 01/15/2025
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Provider Practice Location Address
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Address Line | 1217 BONITA ST
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City | GRANTS
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State | NM
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Zip | 87020-2103
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Country | US
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Telephone | 52-872-9585
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Fax | 505-443-8342
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Provider Business Mailing Address
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Address Line | 1217 BONITA ST
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City | GRANTS
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State | NM
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Zip | 87020-2103
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Country | US
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Telephone | 52-872-9585
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Fax | 505-443-8342
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 5905
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | F07161203
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 66164
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License Number State | NM
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