Healthcare Provider Details

I. General information

NPI: 1710270921
Provider Name (Legal Business Name): LAKE AREA DERMATOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2011
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 TALMAGE CIR SUITE 216
VADNAIS HEIGHTS MN
55110-4183
US

IV. Provider business mailing address

2854 HIGHWAY 55 SUITE 130
EAGAN MN
55121-1447
US

V. Phone/Fax

Practice location:
  • Phone: 651-224-4930
  • Fax: 651-842-3391
Mailing address:
  • Phone: 651-224-4930
  • Fax: 651-842-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACY FUCHS GANNON
Title or Position: PRESIDENT / OWNER
Credential: M.D.
Phone: 651-224-4930