MEDICARE: MICHELLE LHOTKA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	01107	WV
2	363A00000X	Physician Assistant	11609	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001807776	OTHER	WV	BLUE CROSS BLUE SHIELD
2	1069730	OTHER	WV	WORKERS COMPENSATION

General Provider Information

NPI Number	:	1467407379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE LHOTKA PA-C

Provider Business Mailing Address
First Line	:	8170 33RD AVE SOUTH
Second Line	:	21110Q
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55430-1309
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3900 PARK NICOLLET BLVD
Second Line	:
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-2503
Country	:	US
Telephone Number	:	952-993-3150
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	09/02/2016

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