Provider Demographics
NPI:1154556942
Name:PETERSON, LEAH (PA-C)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
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 1:1002 LANTERN LN
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7455 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-1181
Practice Address - Country:US
Practice Address - Phone:651-717-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10594363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical