Healthcare Provider Details

I. General information

NPI: 1750320487
Provider Name (Legal Business Name): ELIZABETH N BOYUM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14305 SOUTHCROSS DR W STE 110
BURNSVILLE MN
55306-7011
US

IV. Provider business mailing address

14305 SOUTHCROSS DR W STE 110
BURNSVILLE MN
55306-7011
US

V. Phone/Fax

Practice location:
  • Phone: 513-401-0646
  • Fax:
Mailing address:
  • Phone: 651-340-1064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9778
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: