Healthcare Provider Details

I. General information

NPI: 1750890281
Provider Name (Legal Business Name): LAURA M POTHAST PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 42ND AVE N
NEW HOPE MN
55427-1107
US

IV. Provider business mailing address

1240 S 2ND ST UNIT 106
MINNEAPOLIS MN
55415-2603
US

V. Phone/Fax

Practice location:
  • Phone: 762-581-5700
  • Fax:
Mailing address:
  • Phone: 952-239-7980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14182
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4211-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: