Healthcare Provider Details

I. General information

NPI: 1144223009
Provider Name (Legal Business Name): TWIN CITIES DERMATOPATHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 13TH AVENUE NORTH SUITE 2A
PLYMOUTH MN
55441-5035
US

IV. Provider business mailing address

9900 13TH AVENUE NORTH SUITE 2A
PLYMOUTH MN
55441-5035
US

V. Phone/Fax

Practice location:
  • Phone: 763-525-0363
  • Fax: 763-525-0369
Mailing address:
  • Phone: 763-525-0363
  • Fax: 763-525-0369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number1279
License Number StateMN

VIII. Authorized Official

Name: LISA COOMBE
Title or Position: BUSINESS ADMINISTRATOR
Credential:
Phone: 763-525-0363