Provider Demographics
NPI:1487889929
Name:WEGENER, BRITA LARA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:BRITA
Middle Name:LARA
Last Name:WEGENER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 LAKE ST S
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2628
Mailing Address - Country:US
Mailing Address - Phone:651-464-7100
Mailing Address - Fax:
Practice Address - Street 1:1540 LAKE ST S
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2628
Practice Address - Country:US
Practice Address - Phone:651-464-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical