Provider Demographics
NPI:1588095160
Name:LEE, MICHAEL MOON (LAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MOON
Last Name:LEE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 W 21ST ST
Mailing Address - Street 2:APT. 904
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-6805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 W 21ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6805
Practice Address - Country:US
Practice Address - Phone:201-951-1879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-06
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00101000171100000X
NY005034-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist