Provider Demographics
NPI:1437930278
Name:LIFESPARK MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:LIFESPARK MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LAURING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-345-3213
Mailing Address - Street 1:5320 W 23RD ST STE 130
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1670
Mailing Address - Country:US
Mailing Address - Phone:523-453-3109
Mailing Address - Fax:952-345-8771
Practice Address - Street 1:5320 W 23RD ST STE 130
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1670
Practice Address - Country:US
Practice Address - Phone:952-345-3310
Practice Address - Fax:952-345-8771
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:-
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty