Provider Demographics
NPI:1245218254
Name:LEECH, TODD G (PA-C)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:G
Last Name:LEECH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2502
Mailing Address - Country:US
Mailing Address - Phone:651-254-4786
Mailing Address - Fax:651-254-9426
Practice Address - Street 1:1300 S 2ND ST STE 180
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-5000
Practice Address - Country:US
Practice Address - Phone:612-625-1562
Practice Address - Fax:612-626-8311
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9204363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0111791OtherMEDICA (MN)
NA2951023880OtherPREFERRED ONE (MN)
874112OtherAMERICA'S PPO (MN)
0966523OtherMEDICAID (IOWA)
120314OtherUCARE (MN)
MN281724100Medicaid
73A65LEOtherBCBS (MN)
HP41032OtherHEALTH PARTNERS (MN)
970005979OtherRR MEDICARE
MN970000338Medicare PIN