Healthcare Provider Details

I. General information

NPI: 1316295215
Provider Name (Legal Business Name): CHERYL ANN LUCIUS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 25TH AVE S 601 25TH AVE SO.
MINNEAPOLIS MN
55454-1454
US

IV. Provider business mailing address

2094 WILLOW CIR 2094 WILLOW CIRCLE
CENTERVILLE MN
55038-8774
US

V. Phone/Fax

Practice location:
  • Phone: 651-690-7772
  • Fax:
Mailing address:
  • Phone: 651-447-9250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number201143
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: