Healthcare Provider Details

I. General information

NPI: 1205446945
Provider Name (Legal Business Name): TRISHA DOMANTAY LAXAMANA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date: 10/20/2021
Reactivation Date: 02/21/2022

III. Provider practice location address

200 1ST ST SW
ROCHESTER MN
55905-0002
US

IV. Provider business mailing address

PO BOX 860912
MINNEAPOLIS MN
55486-0912
US

V. Phone/Fax

Practice location:
  • Phone: 507-284-2511
  • Fax: 507-284-0702
Mailing address:
  • Phone: 507-284-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number79360
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: