Provider Demographics
NPI:1588997308
Name:LUNDGREN, LAURA M (PA C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:M
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2105 E ENTERPRISE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-560-1000
Mailing Address - Fax:920-731-7133
Practice Address - Street 1:2105 E ENTERPRISE AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7862
Practice Address - Country:US
Practice Address - Phone:920-560-1000
Practice Address - Fax:920-731-7133
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2505-23363AS0400X
WI2505363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical