Provider Demographics
NPI:1215120555
Name:LEE, LAURIE W (PA)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:W
Last Name:LEE
Suffix:
Gender:F
Credentials:PA
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 30727
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28230-0727
Mailing Address - Country:US
Mailing Address - Phone:843-237-3378
Mailing Address - Fax:843-237-5073
Practice Address - Street 1:615 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4629
Practice Address - Country:US
Practice Address - Phone:843-237-3378
Practice Address - Fax:843-237-5073
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2769947Medicare PIN