Provider Demographics
NPI:1013752096
Name:LEE, JAEHO JOSHUA (PA-C)
Entity type:Individual
Prefix:
First Name:JAEHO
Middle Name:JOSHUA
Last Name:LEE
Suffix:
Gender:M
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 1:2253 DAISY LN
Mailing Address - Street 2:
Mailing Address - City:LA CANADA FLINTRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91011-1412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 4TH ST
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:CA
Practice Address - Zip Code:93926
Practice Address - Country:US
Practice Address - Phone:831-290-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA66825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program