Provider Demographics
NPI:1467407379
Name:LHOTKA, MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LHOTKA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE SOUTH
Mailing Address - Street 2:21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55430-1309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 PARK NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2503
Practice Address - Country:US
Practice Address - Phone:952-993-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01107363A00000X
MN11609363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001807776OtherBLUE CROSS BLUE SHIELD
WV1069730OtherWORKERS COMPENSATION
WV001807776OtherBLUE CROSS BLUE SHIELD