Basic Information
Provider Information | |||||||||
NPI: | 1790952612 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAPOSKY | ||||||||
FirstName: | NATHAN | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 523 N 3RD ST | ||||||||
Address2: |   | ||||||||
City: | BRAINERD | ||||||||
State: | MN | ||||||||
PostalCode: | 564013054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188292861 | ||||||||
FaxNumber: | 2185299120 | ||||||||
Practice Location | |||||||||
Address1: | 523 N 3RD ST | ||||||||
Address2: |   | ||||||||
City: | BRAINERD | ||||||||
State: | MN | ||||||||
PostalCode: | 564013054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188292861 | ||||||||
FaxNumber: | 2188283103 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2008 | ||||||||
LastUpdateDate: | 12/28/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 51978 | MN | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207P00000X | 51978 | MN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 01-37336 | 01 |   | MEDICA | OTHER | 1790952612 | 01 |   | GROUP HEALTH | OTHER | 1790952612 | 05 | MN |   | MEDICAID | P00767172 | 01 |   | MEDICARE RAILROAD | OTHER | 1790952612 | 01 | MN | BCBS | OTHER |