Provider Demographics
NPI:1154692887
Name:LEE, ANTHONY KOU (PA-C)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:KOU
Last Name:LEE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 WEST MICHAELS DRIVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8400
Mailing Address - Country:US
Mailing Address - Phone:920-585-4846
Mailing Address - Fax:
Practice Address - Street 1:5320 W MICHAELS DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8446
Practice Address - Country:US
Practice Address - Phone:920-585-4846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2889-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100032441Medicaid