Healthcare Provider Details

I. General information

NPI: 1265287163
Provider Name (Legal Business Name): MADELINE LOCKHART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18465 ORCHARD TRL
LAKEVILLE MN
55044-8885
US

IV. Provider business mailing address

PO BOX 43
MINNEAPOLIS MN
55440-0043
US

V. Phone/Fax

Practice location:
  • Phone: 952-428-0950
  • Fax:
Mailing address:
  • Phone: 612-262-1166
  • Fax: 612-262-4258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14993
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: