Provider Demographics
NPI:1417924994
Name:SUTHERLAND, LOLA B (MD)
Entity Type:Individual
Prefix:
First Name:LOLA
Middle Name:B
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LOLA
Other - Middle Name:M
Other - Last Name:SUTHERLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE NO
Mailing Address - Street 2:CENTRA CARE CLINIC
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:763-263-7300
Mailing Address - Fax:
Practice Address - Street 1:16830 198TH AVE NW
Practice Address - Street 2:BIG LAKE CLINIC
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309
Practice Address - Country:US
Practice Address - Phone:763-263-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN26313207Q00000X
MN26313207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D75515Medicare UPIN