Provider Demographics
NPI:1194097311
Name:LEE, EMILY ANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:ANN
Last Name:LEE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:EMILY
Other - Middle Name:ANN
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10400 75TH
Mailing Address - Street 2:STE 215
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-8323
Mailing Address - Country:US
Mailing Address - Phone:262-948-7380
Mailing Address - Fax:
Practice Address - Street 1:10400 75TH ST STE 215
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7884
Practice Address - Country:US
Practice Address - Phone:262-948-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0800363A00000X
WI3731-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6837080Medicaid
SDS105895Medicare PIN