Provider Demographics
NPI:1558815522
Name:LEE, JAEWON (CNP)
Entity type:Individual
Prefix:
First Name:JAEWON
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:JAE WON
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:1217 BONITA ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2103
Mailing Address - Country:US
Mailing Address - Phone:052-872-9585
Mailing Address - Fax:505-443-8342
Practice Address - Street 1:1217 BONITA ST
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2103
Practice Address - Country:US
Practice Address - Phone:052-872-9585
Practice Address - Fax:505-443-8342
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5905363L00000X
INF07161203363LF0000X
NM66164363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner