1578522009 NPI number — LAURA M GANDRUD PICKETT MD

Table of content: LAURA M GANDRUD PICKETT MD (NPI 1578522009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578522009 NPI number — LAURA M GANDRUD PICKETT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANDRUD PICKETT
Provider First Name:
LAURA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578522009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3800 PARK NICOLLET BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST LOUIS PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55416-2527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-993-3123
Provider Business Mailing Address Fax Number:
651-855-2310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3800 PARK NICOLLET BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416-2527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-993-3123
Provider Business Practice Location Address Fax Number:
651-855-2310
Provider Enumeration Date:
03/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  48276 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0205X , with the licence number: 48276 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 483695200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".