Provider Demographics
NPI:1629645031
Name:LEITHEISER, TRACI L (MPAS, PA-C)
Entity Type:Individual
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First Name:TRACI
Middle Name:L
Last Name:LEITHEISER
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Gender:F
Credentials:MPAS, PA-C
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-312-2373
Mailing Address - Fax:605-312-9802
Practice Address - Street 1:5225 23RD AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7927
Practice Address - Country:US
Practice Address - Phone:701-417-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-06
Last Update Date:2021-10-13
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant