Provider Demographics
NPI:1245217181
Name:ROSS, LAURA JOYCE-CARLSON (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:JOYCE-CARLSON
Last Name:ROSS
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6500 EXCELSIOR BLVD
Mailing Address - Street 2:PARK NICOLLET HEART AND VASCULAR CENTER
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4702
Mailing Address - Country:US
Mailing Address - Phone:952-993-2304
Mailing Address - Fax:952-993-3010
Practice Address - Street 1:6500 EXCELSIOR BLVD
Practice Address - Street 2:PARK NICOLLET HEART AND VASCULAR CENTER
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4702
Practice Address - Country:US
Practice Address - Phone:952-993-2304
Practice Address - Fax:952-993-3010
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN9898363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN463918900Medicaid
MN970002159Medicare ID - Type Unspecified
MNQ37969Medicare UPIN