MEDICARE: JOHN K LEE

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	163WM0705X	Medical-Surgical Registered Nurse	RN582630	PA

General Provider Information

NPI Number	:	1881266245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN K LEE

Provider Business Mailing Address
First Line	:	6930 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1805
Country	:	US
Telephone Number	:	215-268-8388
Fax Number	:

Provider Business Practice Location Address
First Line	:	6930 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1805
Country	:	US
Telephone Number	:	215-268-8388
Fax Number	:

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

Provider Enumeration Date	:	07/14/2021
Last Update Date	:	07/14/2021

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