Provider Demographics
NPI:1811499643
Name:LEE, JOSHUA NAOTOU
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:NAOTOU
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 1:2060 CENTRE POINTE BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1271
Mailing Address - Country:US
Mailing Address - Phone:651-774-0011
Mailing Address - Fax:
Practice Address - Street 1:15565 XKIMO CT NW
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:MN
Practice Address - Zip Code:55303-5718
Practice Address - Country:US
Practice Address - Phone:612-791-8527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA150632100OtherUNIQUE MINNESOTA PROVIDER ID