Basic Information
| Provider Information | |||||||||
| NPI: | 1134141393 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10705 TOWN SQUARE DR NE STE 100 | ||||||||
| Address2: | |||||||||
| City: | BLAINE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554498185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632365400 | ||||||||
| FaxNumber: | 7632365350 | ||||||||
| Practice Location | |||||||||
| Address1: | 10705 TOWN SQUARE DR NE STE 100 | ||||||||
| Address2: | |||||||||
| City: | BLAINE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554498185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632365400 | ||||||||
| FaxNumber: | 7632365350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 04/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS13620 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 42990 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1134141393 | 05 | MN | MEDICAID | 33181 | 01 | FL | BCBS FLORIDA | OTHER |