Basic Information
| Provider Information | |||||||||
| NPI: | 1619383684 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MATHESON | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1309 | ||||||||
| Address2: | 8170 33RD AVE S - MAIL STOP 21110Q | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512543456 | ||||||||
| FaxNumber: | 6512549673 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 JACKSON STREET | ||||||||
| Address2: | MC 11109E | ||||||||
| City: | ST. PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551012502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512543456 | ||||||||
| FaxNumber: | 6512549673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2014 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
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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 | 363AM0700X | 2096 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 11598 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.