Basic Information
| Provider Information | |||||||||
| NPI: | 1396929311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUCE | ||||||||
| FirstName: | LOLITA | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 2ND AVE S STE 400 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554023318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122251538 | ||||||||
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| Practice Location | |||||||||
| Address1: | 920 2ND AVE S STE 400 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554023318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122251538 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2007 | ||||||||
| LastUpdateDate: | 05/24/2012 | ||||||||
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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 | PA04817 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2035487-01 | 05 | TX | MEDICAID | 2067738-01 | 05 | TX | MEDICAID | 206773802 | 05 | TX | MEDICAID | 206773801 | 05 | TX | MEDICAID | D07564 | 01 | TX | MEDICARE RR PALMETTO | OTHER | DQ5280 | 01 | TX | MEDICARE RR PALMETTO | OTHER |