Basic Information
| Provider Information | |||||||||
| NPI: | 1710270921 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE AREA DERMATOLOGY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2854 HIGHWAY 55 | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551211447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512244930 | ||||||||
| FaxNumber: | 6518423391 | ||||||||
| Practice Location | |||||||||
| Address1: | 3640 TALMAGE CIR | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | VADNAIS HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551104183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512244930 | ||||||||
| FaxNumber: | 6518423391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2011 | ||||||||
| LastUpdateDate: | 06/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | GANNON | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | FUCHS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6512244930 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.