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General NPI Number Information
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NPI Number | 1881143022
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Entity Type | Individual
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Provider Name | LISA LEEDHAM PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/29/2016
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Last Update Date | 11/09/2020
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Provider Practice Location Address
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Address Line | 512 SKYLINE BLVD
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City | CLOQUET
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State | MN
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Zip | 55720-3787
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Country | US
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Telephone | 218-879-4641
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Fax | 218-879-9167
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Provider Business Mailing Address
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Address Line | 512 SKYLINE BLVD
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City | CLOQUET
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State | MN
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Zip | 55720-1199
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Country | US
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Telephone | 218-879-4641
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Fax | 218-879-9167
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 5601007983
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License Number State | MI
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