Provider Demographics
NPI:1366401705
Name:ATHEARN, CHERYL P (PA)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:P
Last Name:ATHEARN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2502
Mailing Address - Country:US
Mailing Address - Phone:651-254-1804
Mailing Address - Fax:
Practice Address - Street 1:4320 SEMINARY RD
Practice Address - Street 2:ALEXANDRIA HOSPITAL
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304
Practice Address - Country:US
Practice Address - Phone:703-504-3066
Practice Address - Fax:703-504-3866
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10775363A00000X
FLPA9107831363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00339583OtherRAILROAD MEDICARE
MDP62082Medicare UPIN
VA009730E14Medicare ID - Type Unspecified
MDK727M880Medicare PIN