Provider Demographics
NPI:1588478820
Name:LEE, ETHAN (PA-C)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:LEE
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6523
Mailing Address - Fax:570-271-8056
Practice Address - Street 1:1525 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:HAZLE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18202-9383
Practice Address - Country:US
Practice Address - Phone:570-751-5900
Practice Address - Fax:570-751-5901
Is Sole Proprietor?:No
Enumeration Date:2025-02-06
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA066314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant