Provider Demographics
NPI:1477134336
Name:GROSSOEHME, LUCAS ALLEN
Entity Type:Individual
Prefix:MR
First Name:LUCAS
Middle Name:ALLEN
Last Name:GROSSOEHME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1879 FERONIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3549
Mailing Address - Country:US
Mailing Address - Phone:651-646-4061
Mailing Address - Fax:
Practice Address - Street 1:1879 FERONIA AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3549
Practice Address - Country:US
Practice Address - Phone:651-646-4061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0739339225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist