Provider Demographics
NPI:1306800842
Name:LASTINE, MICHAEL L (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:LASTINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:920 4TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:PIPESTONE
Mailing Address - State:MN
Mailing Address - Zip Code:56164-1455
Mailing Address - Country:US
Mailing Address - Phone:507-825-5700
Mailing Address - Fax:507-825-4752
Practice Address - Street 1:920 4TH AVE SW
Practice Address - Street 2:
Practice Address - City:PIPESTONE
Practice Address - State:MN
Practice Address - Zip Code:56164-1455
Practice Address - Country:US
Practice Address - Phone:507-825-5700
Practice Address - Fax:507-825-4752
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN23174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080056192OtherRR MEDICARE
MN867592900Medicaid
SD7788113Medicaid
IA1912212Medicaid
IA1912212Medicaid
SD7788113Medicaid