Provider Demographics
NPI:1386413946
Name:KOSTOS, LAURA GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:GRACE
Last Name:KOSTOS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 860912
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0912
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:1101 MOULTON & PARSONS DR
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:MN
Practice Address - Zip Code:56081-0460
Practice Address - Country:US
Practice Address - Phone:507-375-3391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-25
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant