Provider Demographics
NPI:1043566003
Name:GROTZINGER, LAURIE K (PA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:K
Last Name:GROTZINGER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 S MAPLE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1733
Mailing Address - Country:US
Mailing Address - Phone:952-442-7804
Mailing Address - Fax:
Practice Address - Street 1:560 S MAPLE ST
Practice Address - Street 2:SUITE 400
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1733
Practice Address - Country:US
Practice Address - Phone:952-442-7804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11354363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB2621016Medicare PIN