MEDICARE: KWANGJA LEE HONG CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	1507	CA

General Provider Information

NPI Number	:	1427017029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KWANGJA LEE HONG CRNA

Provider Business Mailing Address
First Line	:	PO BOX 1810
Second Line	:
City	:	LAKE ARROWHEAD
State	:	CA
Zip	:	92352
Country	:	US
Telephone Number	:	316-281-3700
Fax Number	:	316-282-4322

Provider Business Practice Location Address
First Line	:	29101 HOSPITAL ROAD
Second Line	:
City	:	LAKE ARROWHEAD
State	:	CA
Zip	:	92352
Country	:	US
Telephone Number	:	909-336-3651
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	05/26/2011

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