Provider Demographics
NPI:1588903009
Name:DAVIDSON, LAURA (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3365 PLYMOUTH BLVD.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446
Mailing Address - Country:US
Mailing Address - Phone:612-486-4200
Mailing Address - Fax:
Practice Address - Street 1:3365 PLYMOUTH BLVD.
Practice Address - Street 2:SUITE 110
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446
Practice Address - Country:US
Practice Address - Phone:612-486-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant