Provider Demographics
NPI:1306098819
Name:LEE, ROBERT ALAN
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALAN
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 1:1095 KOOGLE RD
Mailing Address - Street 2:APT 199
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-9136
Mailing Address - Country:US
Mailing Address - Phone:419-589-0227
Mailing Address - Fax:
Practice Address - Street 1:1095 KOOGLE RD
Practice Address - Street 2:APT 199
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-9136
Practice Address - Country:US
Practice Address - Phone:419-589-0227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2786703374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2786703Medicaid