Basic Information
| Provider Information | |||||||||
| NPI: | 1881858363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODER | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | EVAVOLD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EVAVOLD | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | CORINNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8170 33RD AVE S | ||||||||
| Address2: | PO BOX 1309 MAIL STOP 21110Q | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529934001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1885 PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551222979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529934001 | ||||||||
| FaxNumber: | 9529934095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2008 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 52647 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.