NPIMap

Individual provider Active NPI

Miranda Marie Lacroix, PA-STUDENT

  • Physician Assistant
  • Saint Paul, MN
National Provider Identifier
1942815980
Registry record updated Dec 6, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
13913 Issued in MN
Practice address
640 Jackson St
Saint Paul, MN 55101-2502
Phone
(651) 254-3456
NPI assigned
Sep 15, 2020
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 6, 2021

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 13913 MN Primary

Addresses

Primary practice location

640 Jackson St
Saint Paul, MN 55101-2502

Mailing address

640 Jackson St
Saint Paul, MN 55101-2595
Phone (651) 254-3456

Other practice location 1

1204 Black Oak Dr
New Brighton, MN 55112-8432
Phone (920) 242-3001

Other identifiers 1

IdentifierTypeStateIssuer
378862OtherWIWISCONSIN NURSE AIDE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20220103000697 MN Practitioner - Physician Assistant 0648661579 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2021
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Park Nicollet ClinicGroup PAC ID 7911819438, 1,778 clinicians
Group Health IncGroup PAC ID 1759293954, 1,627 clinicians

Practice addresses (Care Compare)

5320 Hyland Greens Dr
Bloomington, MN 55437-3934
Phone (952) 993-2400

640 Jackson St
Saint Paul, MN 55101-2502
Phone (651) 221-3456

6500 Excelsior Blvd
St Louis Park, MN 55426-4702
Phone (952) 993-3123

8600 Nicollet Ave
Bloomington, MN 55420-2824
Phone (952) 884-1148

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
13913MNMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Group Health, Inc. CurrentSince Jan 1, 2022 Accepting new patients
Group Health, Inc. CurrentSince Jan 1, 2022 Accepting new patients
Park Nicollet Clinic CurrentSince Jan 17, 2023 Accepting new patients
Park Nicollet Clinic CurrentSince Jan 17, 2023 Accepting new patients
Group Health, Inc. Past Accepting new patients

Locations

8170 33rd Ave S
#21110Q
Minneapolis, MN 55425
Phone (952) 883-5375

8600 Nicollet Ave S
Minneapolis, MN 55420
Phone (952) 887-6600

5320 Hyland Greens Dr
Minneapolis, MN 55437
Phone (952) 993-2400

640 Jackson St
Saint Paul, MN 55101
Phone (651) 221-2164

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 18

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 18

NPI Registry JSON

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

{
    "created_epoch": "1600128000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1638748800000",
    "number": "1942815980",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "640 JACKSON ST",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551012595",
            "telephone_number": "651-254-3456"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "640 JACKSON ST",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551012502",
            "telephone_number": "651-254-3456"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1204 Black Oak Dr",
            "address_purpose": "LOCATION",
            "city": "New Brighton",
            "state": "MN",
            "postal_code": "551128432",
            "country_code": "US",
            "telephone_number": "920-242-3001",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "LACROIX",
        "first_name": "MIRANDA",
        "middle_name": "MARIE",
        "credential": "PA-STUDENT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2020-09-15",
        "last_updated": "2021-12-06",
        "certification_date": "2021-12-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MN",
            "license": "13913",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WISCONSIN NURSE AIDE",
            "identifier": "378862",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Paul, MN

Sources for this page

Verify at the official NPI Registry.