Provider Demographics
NPI:1710270921
Name:LAKE AREA DERMATOLOGY PA
Entity Type:Organization
Organization Name:LAKE AREA DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:FUCHS
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-224-4930
Mailing Address - Street 1:2854 HIGHWAY 55
Mailing Address - Street 2:SUITE 130
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1447
Mailing Address - Country:US
Mailing Address - Phone:651-224-4930
Mailing Address - Fax:651-842-3391
Practice Address - Street 1:3640 TALMAGE CIR
Practice Address - Street 2:SUITE 216
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55110-4183
Practice Address - Country:US
Practice Address - Phone:651-224-4930
Practice Address - Fax:651-842-3391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-20
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty