Provider Demographics
NPI:1619383684
Name:MATHESON, LEAH C
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:C
Last Name:MATHESON
Suffix:
Gender:F
Credentials:
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1309
Mailing Address - Street 2:8170 33RD AVE S - MAIL STOP 21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-254-3456
Mailing Address - Fax:651-254-9673
Practice Address - Street 1:640 JACKSON STREET
Practice Address - Street 2:MC 11109E
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3456
Practice Address - Fax:651-254-9673
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN2096363AM0700X
MN11598363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical