Individual
LAURA WOODBECK MOUSTAFA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
12720 BASS LAKE RD, MAPLE GROVE, MN 55369-6307
(763) 559-2861
Mailing address
12720 BASS LAKE RD, MAPLE GROVE, MN 55369-6307
(763) 559-2861
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
61732
MN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/21/2014
Last updated
05/11/2021
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