MEDICARE: LAKE AREA DERMATOLOGY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1710270921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE AREA DERMATOLOGY PA

Provider Business Mailing Address
First Line	:	2854 HIGHWAY 55
Second Line	:	SUITE 130
City	:	EAGAN
State	:	MN
Zip	:	55121-1447
Country	:	US
Telephone Number	:	651-224-4930
Fax Number	:	651-842-3391

Provider Business Practice Location Address
First Line	:	3640 TALMAGE CIR
Second Line	:	SUITE 216
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-4183
Country	:	US
Telephone Number	:	651-224-4930
Fax Number	:	651-842-3391

Authorized Official
Title or Position	:	PRESIDENT / OWNER
Name	:	TRACY FUCHS GANNON
Credential	:	M.D.
Telephone Number	:	651-224-4930

Provider Enumeration Date	:	05/20/2011
Last Update Date	:	06/03/2011

Similar Medicare Providers

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Practice Location Address:

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Directions to “LAKE AREA DERMATOLOGY PA ” Practice Location

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