Provider Demographics
NPI:1578522009
Name:GANDRUD PICKETT, LAURA M (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:GANDRUD PICKETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 PARK NICOLLET BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2527
Mailing Address - Country:US
Mailing Address - Phone:952-993-3123
Mailing Address - Fax:651-855-2310
Practice Address - Street 1:3800 PARK NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3123
Practice Address - Fax:651-855-2310
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48276208000000X, 2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN483695200Medicaid
MN483695200Medicaid