Provider Demographics
NPI:1588194021
Name:LEERS, MITCHEL (PA-C)
Entity type:Individual
Prefix:
First Name:MITCHEL
Middle Name:
Last Name:LEERS
Suffix:
Gender:M
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 1:1700 UNIVERSITY AVE W FL 6
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6936 PINE ARBOR DR S STE 100
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4661
Practice Address - Country:US
Practice Address - Phone:651-326-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5420363A00000X
MN13346363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant