Provider Demographics
NPI:1194316604
Name:LEE, JASON GONG-FUNG (PA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:GONG-FUNG
Last Name:LEE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9695 BASE LINE RD
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1314
Mailing Address - Country:US
Mailing Address - Phone:626-941-0920
Mailing Address - Fax:
Practice Address - Street 1:9695 BASE LINE RD
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1314
Practice Address - Country:US
Practice Address - Phone:909-940-0920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA59315363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical