Provider Demographics
NPI:1063452217
Name:KOEPP, LORA LEE E (PNP)
Entity Type:Individual
Prefix:
First Name:LORA LEE
Middle Name:E
Last Name:KOEPP
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-6005
Mailing Address - Fax:612-630-8242
Practice Address - Street 1:5 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3117
Practice Address - Country:US
Practice Address - Phone:612-545-9000
Practice Address - Fax:612-545-9049
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20000365363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN12-01355OtherMEDICA
MN40D83KOOtherBLUE CROSS BLUE SHIELD
MN887019500Medicaid
MNP21047Medicare UPIN
MN500001478Medicare Oscar/Certification
MN12-01355OtherMEDICA