Individual
JOHNATHAN TYREE DIETRICH LEE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
6333 CENTER DR, INTERSTATE CORPORATE CENTER # 16, NORFOLK, VA 23502-4126
(540) 448-0719
Mailing address
6333 CENTER DR, INTERSTATE CORPORATE CENTER # 16, NORFOLK, VA 23502-4126
(540) 448-0719
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
0110005004
VA
363AM0700X
Medical Physician Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0110005004
VIRGINIA MEDICAL LICENSE
VA
Enumeration date
06/04/2015
Last updated
03/12/2021
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