Provider Demographics
NPI:1285800045
Name:REGINA K LEE MD PA
Entity type:Organization
Organization Name:REGINA K LEE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEHAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-615-9990
Mailing Address - Street 1:PO BOX 2205
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78298-2205
Mailing Address - Country:US
Mailing Address - Phone:210-393-3812
Mailing Address - Fax:
Practice Address - Street 1:10515 SH 151 STE 240
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4409
Practice Address - Country:US
Practice Address - Phone:210-393-3812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM8786OtherLICENSE