Provider Demographics
NPI:1528102084
Name:WILLSON, LAURA ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:WILLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2122 JULIET AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 EAST 28TH STREET
Practice Address - Street 2:MAIL ROUTE 11118
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3799
Practice Address - Country:US
Practice Address - Phone:612-863-4060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN176932085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology