Healthcare Provider Details

I. General information

NPI: 1629707849
Provider Name (Legal Business Name): EMMA B BENGTSON PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 CARLSON ST
MARSHALL MN
56258-2626
US

IV. Provider business mailing address

2355 US HIGHWAY 59
GARVIN MN
56132-1161
US

V. Phone/Fax

Practice location:
  • Phone: 507-476-4800
  • Fax:
Mailing address:
  • Phone: 402-871-0617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14678
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: