Healthcare Provider Details

I. General information

NPI: 1043760820
Provider Name (Legal Business Name): AMANDA LAATSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1185 TOWN CENTRE DR STE 205
EAGAN MN
55123-1370
US

IV. Provider business mailing address

PO BOX 14909
MINNEAPOLIS MN
55414-0909
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-1145
  • Fax: 612-870-5491
Mailing address:
  • Phone: 612-871-1145
  • Fax: 612-870-5491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA058619
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12870
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: