Basic Information
| Provider Information | |||||||||
| NPI: | 1578859518 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOERITZ | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREIS | ||||||||
| OtherFirstName: | LYDIA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2001 BLAISDELL AVE S | ||||||||
| Address2: | PARK NICOLLET CLINIC | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529938000 | ||||||||
| FaxNumber: | 9529938039 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 BLAISDELL AVE S | ||||||||
| Address2: | PARK NICOLLET CLINIC | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529938000 | ||||||||
| FaxNumber: | 9529938039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2011 | ||||||||
| LastUpdateDate: | 03/31/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | G0611003 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | R179498-8 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 163W00000X | R179494-8 | MN | N | Nursing Service Providers | Registered Nurse |
No ID Information.