Provider Demographics
NPI:1154423770
Name:LEE, MIAE (CRNA)
Entity type:Individual
Prefix:
First Name:MIAE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5486
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5486
Mailing Address - Country:US
Mailing Address - Phone:818-550-0900
Mailing Address - Fax:505-293-1524
Practice Address - Street 1:3300 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3120
Practice Address - Country:US
Practice Address - Phone:707-725-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACRNA2665207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN4693190Medicaid
CAP37553Medicare UPIN
CAZZZ01785ZMedicare ID - Type Unspecified
CA0A2665Medicare ID - Type Unspecified