Provider Demographics
NPI:1487731212
Name:WILLSON, LEAH M (MD)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:M
Last Name:WILLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CENTURY AVE SE
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-3108
Mailing Address - Country:US
Mailing Address - Phone:320-587-2020
Mailing Address - Fax:320-234-3295
Practice Address - Street 1:3 CENTURY AVE SE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-3108
Practice Address - Country:US
Practice Address - Phone:320-587-2020
Practice Address - Fax:320-234-3295
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39279208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA03151Medicare UPIN