MEDICARE: LISA LEGVOLD 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	11762	MN

General Provider Information

NPI Number	:	1518357102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA LEGVOLD PA-C

Provider Business Mailing Address
First Line	:	820 SPRINGER DR
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-6413
Country	:	US
Telephone Number	:	815-744-8554
Fax Number	:

Provider Business Practice Location Address
First Line	:	4725 36TH AVE N
Second Line	:
City	:	CRYSTAL
State	:	MN
Zip	:	55422-2169
Country	:	US
Telephone Number	:	218-208-2058
Fax Number	:

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

Provider Enumeration Date	:	02/03/2015
Last Update Date	:	01/25/2022

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Directions to “ LISA LEGVOLD PA-C” Practice Location

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