Provider Demographics
NPI:1013592708
Name:SUNDBERG, LEIF PER-ALDEN (PA-C)
Entity Type:Individual
Prefix:
First Name:LEIF
Middle Name:PER-ALDEN
Last Name:SUNDBERG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2025 SLOAN PL STE 35
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2092
Mailing Address - Country:US
Mailing Address - Phone:651-772-1572
Mailing Address - Fax:651-772-1889
Practice Address - Street 1:4786 BANNING AVE
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3264
Practice Address - Country:US
Practice Address - Phone:651-426-6402
Practice Address - Fax:651-429-3402
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-14
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN13719363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant