Basic Information
| Provider Information | |||||||||
| NPI: | 1114959814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOUQUETTE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8100 34TH AVE S | ||||||||
| Address2: | MC21110Q | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554251672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528837172 | ||||||||
| FaxNumber: | 9528835395 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 WAITE AVE S | ||||||||
| Address2: | |||||||||
| City: | WAITE PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563871348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202591334 | ||||||||
| FaxNumber: | 3202032414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9992 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.