Provider Demographics
NPI:1831489483
Name:HAGEMEYER, LAURA JOY (MD)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JOY
Last Name:HAGEMEYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:JOY
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:MMC 391
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-624-4417
Mailing Address - Fax:612-626-7042
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:MMC 391
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0341
Practice Address - Country:US
Practice Address - Phone:612-624-4417
Practice Address - Fax:612-626-7042
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-17
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN55640208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program