Provider Demographics
NPI:1962868117
Name:LEE, RAY
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:
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 1:924 E INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-2559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2470 W PULLMAN RD
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4034
Practice Address - Country:US
Practice Address - Phone:208-882-1344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60286362390200000X
IDE33922390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program