Provider Demographics
NPI:1477092690
Name:GONSHOROWSKI, LAURA ANN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:GONSHOROWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 FAIVIEW AVE N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-241-5290
Mailing Address - Fax:651-241-5248
Practice Address - Street 1:2720 FAIVIEW AVENUE N
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-241-5290
Practice Address - Fax:651-241-5248
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN12354363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant