Lake Area Dermatology PA

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

LAKE AREA DERMATOLOGY PA

Practice address

3640 Talmage Cir
Suite 216
Vadnais Heights, MN 55110-4183

Phone

(651) 224-4930

Fax

(651) 842-3391

NPI assigned

May 20, 2011

Last updated

Jun 3, 2011By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Tracy Fuchs Gannon, M.D.NPI 1720053937

Title

President / Owner

Phone

(651) 224-4930

Specialties & licenses 1

Addresses

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Tracy Fuchs Gannon, MD

  • Dermatology Physician
  • Vadnais Heights, MN
  • NPI 1720053937
  Authorized official Same address or phone
• Wayne David Leroy Bentham, MD

  • Psychiatry Physician
  • Vadnais Heights, MN
  • NPI 1609952407
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1305849600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1307059200000",
    "number": "1710270921",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2854 HIGHWAY 55",
            "address_2": "SUITE 130",
            "city": "EAGAN",
            "state": "MN",
            "postal_code": "551211447",
            "telephone_number": "651-224-4930",
            "fax_number": "651-842-3391"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3640 TALMAGE CIR",
            "address_2": "SUITE 216",
            "city": "VADNAIS HEIGHTS",
            "state": "MN",
            "postal_code": "551104183",
            "telephone_number": "651-224-4930",
            "fax_number": "651-842-3391"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE AREA DERMATOLOGY PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-05-20",
        "last_updated": "2011-06-03",
        "status": "A",
        "authorized_official_last_name": "GANNON",
        "authorized_official_first_name": "TRACY",
        "authorized_official_middle_name": "FUCHS",
        "authorized_official_title_or_position": "PRESIDENT / OWNER",
        "authorized_official_telephone_number": "651-224-4930",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Christine Koentopp, BPHARM
• Jessica Marie Krause, AUD
• Rebecca Paige Krause, PT, DPT
• Lana K Schultz Krumwiede, PT
• Nicole Kwapick
• Ryan Langer, DPT
• Abby C Larsen, DPT
• Katrina Andrada Leano, D.D.S.
• Trevor Lecocq, LPCC
• Ryan Zachary Lee, PT

• Dermatology Physician in Vadnais Heights, MN
• Providers in Vadnais Heights, MN by specialty
• Dermatology Physician in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 3, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.