MEDICARE: LAURA ELIZABETH WILLSON 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	1437	MN

General Provider Information

NPI Number	:	1700198199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA ELIZABETH WILLSON PA-C

Provider Business Mailing Address
First Line	:	1930 GRAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1409
Country	:	US
Telephone Number	:	612-799-9797
Fax Number	:

Provider Business Practice Location Address
First Line	:	1536 HEWITT AVE # MS -C1908
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-1284
Country	:	US
Telephone Number	:	651-523-2204
Fax Number	:

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

Provider Enumeration Date	:	07/14/2010
Last Update Date	:	08/28/2020

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