Provider Demographics
NPI:1396929311
Name:BRUCE, LOLITA THOMAS
Entity type:Individual
Prefix:
First Name:LOLITA
Middle Name:THOMAS
Last Name:BRUCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 2ND AVE S STE 400
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-3318
Mailing Address - Country:US
Mailing Address - Phone:612-225-1538
Mailing Address - Fax:
Practice Address - Street 1:920 2ND AVE S STE 400
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-3318
Practice Address - Country:US
Practice Address - Phone:612-225-1538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2035487-01Medicaid
TX2067738-01Medicaid
TX206773802Medicaid
TX206773801Medicaid
TXD07564OtherMEDICARE RR PALMETTO
TXDQ5280OtherMEDICARE RR PALMETTO
TX206773801Medicaid
TX2035487-01Medicaid
TXTXB102627Medicare PIN
TXTXB102274Medicare PIN
TX8L18799Medicare PIN
TX206773802Medicaid