Provider Demographics
NPI:1518927839
Name:MICKELSON, LAURA A (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14800 KELLEHER CT
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2996
Mailing Address - Country:US
Mailing Address - Phone:612-280-3782
Mailing Address - Fax:
Practice Address - Street 1:14800 KELLEHER CT
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2996
Practice Address - Country:US
Practice Address - Phone:612-280-3782
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 125293-8367500000X
TX#682114367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43406700Medicaid