Provider Demographics
NPI:1750890281
Name:POTHAST, LAURA M (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:POTHAST
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1240 S 2ND ST UNIT 106
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-2603
Mailing Address - Country:US
Mailing Address - Phone:952-239-7980
Mailing Address - Fax:
Practice Address - Street 1:8100 42ND AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55427-1107
Practice Address - Country:US
Practice Address - Phone:762-581-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN14182363A00000X
WI4211-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant