Provider Demographics
NPI:1316903875
Name:LEE, KRISTINA (PA)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
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 1:3904 101ST ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-5725
Mailing Address - Country:US
Mailing Address - Phone:806-771-1166
Mailing Address - Fax:806-687-0380
Practice Address - Street 1:3904 101ST ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-5725
Practice Address - Country:US
Practice Address - Phone:806-771-1166
Practice Address - Fax:806-687-0380
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02301363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S69063Medicare UPIN
82N224Medicare ID - Type Unspecified