Basic Information
| Provider Information | |||||||||
| NPI: | 1992857213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | JEE-YEON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIM | ||||||||
| OtherFirstName: | GRACE | ||||||||
| OtherMiddleName: | JEE-YEON | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 421 SW OAK ST. | ||||||||
| Address2: | STE. 210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039883663 | ||||||||
| FaxNumber: | 5039883015 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 N LOMBARD ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972033006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039885304 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 03/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A87977 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD154466 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 022959 | 05 | OR | MEDICAID |