Healthcare Provider Details

I. General information

NPI: 1588903009
Provider Name (Legal Business Name): LAURA DAVIDSON MPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2013
Last Update Date: 08/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3365 PLYMOUTH BLVD. SUITE 110
PLYMOUTH MN
55446
US

IV. Provider business mailing address

3365 PLYMOUTH BLVD. SUITE 110
PLYMOUTH MN
55446
US

V. Phone/Fax

Practice location:
  • Phone: 612-486-4200
  • Fax:
Mailing address:
  • Phone: 612-486-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1861
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: