Provider Demographics
NPI:1447234299
Name:ROBERTS, LAURA LYNNE (PA C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNNE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LYNNE
Other - Last Name:TELLEFSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:318 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1645
Mailing Address - Country:US
Mailing Address - Phone:218-546-8375
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:320 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1645
Practice Address - Country:US
Practice Address - Phone:218-546-8375
Practice Address - Fax:218-546-4400
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9404363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN579110300Medicaid