Basic Information
| Provider Information | |||||||||
| NPI: | 1366401705 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ATHEARN | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 640 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551012502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512541804 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4320 SEMINARY RD | ||||||||
| Address2: | ALEXANDRIA HOSPITAL | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035043066 | ||||||||
| FaxNumber: | 7035043866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 09/25/2012 | ||||||||
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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 | 363A00000X | 10775 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00339583 | 01 | MD | RAILROAD MEDICARE | OTHER |