Healthcare Provider Details

I. General information

NPI: 1467407379
Provider Name (Legal Business Name): MICHELLE LHOTKA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 PARK NICOLLET BLVD
SAINT LOUIS PARK MN
55416-2503
US

IV. Provider business mailing address

8170 33RD AVE SOUTH 21110Q
MINNEAPOLIS MN
55430-1309
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number01107
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11609
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: