Provider Demographics
NPI:1316369911
Name:NEW LEAF MEDICAL, PLLC
Entity Type:Organization
Organization Name:NEW LEAF MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE SHAREHOLDER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WIITA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-777-2355
Mailing Address - Street 1:3622 COUNTY ROAD 101 S
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-3424
Mailing Address - Country:US
Mailing Address - Phone:952-777-2355
Mailing Address - Fax:
Practice Address - Street 1:3622 COUNTY ROAD 101 S
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-3424
Practice Address - Country:US
Practice Address - Phone:952-777-2355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42376261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty