Provider Demographics
NPI:1811164007
Name:ZUPANCICH, LEAH ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:ANNE
Last Name:ZUPANCICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:ANNE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2545 CHICAGO AVE. S.
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404
Mailing Address - Country:US
Mailing Address - Phone:612-813-8800
Mailing Address - Fax:612-813-8825
Practice Address - Street 1:2545 CHICAGO AVE. S.
Practice Address - Street 2:SUITE 106
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-813-8800
Practice Address - Fax:612-813-8825
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10401363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical