Provider Demographics
NPI:1215285382
Name:LEE, RYAN GABERIEL
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:GABERIEL
Last Name:LEE
Suffix:
Gender:M
Credentials:
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 636
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-0636
Mailing Address - Country:US
Mailing Address - Phone:503-538-4874
Mailing Address - Fax:503-538-1271
Practice Address - Street 1:501 E 1ST ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2909
Practice Address - Country:US
Practice Address - Phone:503-538-4874
Practice Address - Fax:503-538-1271
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500625268Medicaid