Provider Demographics
NPI:1881143022
Name:LEEDHAM, LISA (PA-C)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:LEEDHAM
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 1:512 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1199
Mailing Address - Country:US
Mailing Address - Phone:218-879-4641
Mailing Address - Fax:218-879-9167
Practice Address - Street 1:512 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-3787
Practice Address - Country:US
Practice Address - Phone:218-879-4641
Practice Address - Fax:218-879-9167
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007983363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical