Healthcare Provider Details

I. General information

NPI: 1902581721
Provider Name (Legal Business Name): HANNAH LEE DESROCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2955 XENIUM LN N
PLYMOUTH MN
55441-2666
US

IV. Provider business mailing address

2800 CAMPUS DR STE 10
PLYMOUTH MN
55441-8812
US

V. Phone/Fax

Practice location:
  • Phone: 763-398-6383
  • Fax:
Mailing address:
  • Phone: 763-398-6383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15253
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: