Individual provider Active NPI

Michelle Yoon-Ji Lee, PA-C

  • Physician Assistant
  • Fontana, CA
National Provider Identifier
1053986117
Registry record updated Apr 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
Practice address
17051 Sierra Lakes Pkwy Ste 101
Fontana, CA 92336-1274
Phone
(909) 864-4700
Fax
(909) 428-2191
NPI assigned
May 21, 2021
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 29, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X Primary

Addresses

Primary practice location

17051 Sierra Lakes Pkwy Ste 101
Fontana, CA 92336-1274

Mailing address

3400 Data Dr
Rancho Cordova, CA 95670-7956

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA
Eligible to order & refer
  • Part B services: Yes
  • Medical equipment: Yes
  • Home health: Yes
  • Power mobility devices: Yes
  • Hospice: No
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20230814001284 CA Practitioner - Physician Assistant 5991167546 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2023
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Providence Medical FoundationGroup PAC ID 8921993205, 1,461 clinicians

Practice addresses (Care Compare)

1165 Montgomery Dr
Santa Rosa, CA 95405-4801
Phone (707) 546-3210

12550 Hesperia Rd
Suite 100
Victorville, CA 92395-5873
Phone (760) 241-6666

17095 Main St
Hesperia, CA 92345-6004
Phone (760) 241-6666

19333 Bear Valley Rd
Apple Valley, CA 92308-5149

Merit-based Incentive Payment System (MIPS)

Final score
99.64 of 100Reported as apm
Quality
86.27
Promoting interoperability
100
Improvement activities
40

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Providence Medical Foundation CurrentSince Jun 1, 2025 Accepting new patients
Providence Medical Foundation CurrentSince Jun 1, 2025 Accepting new patients
Providence Medical Foundation Past Accepting new patients

Locations

19333 Bear Valley Rd
Ste 106
Apple Valley, CA 92308
Phone (760) 240-5505

17095 Main St
Hesperia, CA 92345
Phone (760) 948-6606

1165 Montgomery Dr
#1112
Santa Rosa, CA 95405
Phone (707) 546-3210

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1621555200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1714348800000",
    "number": "1053986117",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3400 DATA DR",
            "city": "RANCHO CORDOVA",
            "state": "CA",
            "postal_code": "956707956"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17051 SIERRA LAKES PKWY STE 101",
            "city": "FONTANA",
            "state": "CA",
            "postal_code": "923361274",
            "telephone_number": "909-864-4700",
            "fax_number": "909-428-2191"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LEE",
        "first_name": "MICHELLE",
        "middle_name": "YOON-JI",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-05-21",
        "last_updated": "2024-04-29",
        "certification_date": "2024-04-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fontana, CA

Sources for this page

Verify at the official NPI Registry.