Healthcare Provider Details

I. General information

NPI: 1952870339
Provider Name (Legal Business Name): ELLYN MARIE PHEARMAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 COUNTY ROAD 120
SAINT CLOUD MN
56303-4872
US

IV. Provider business mailing address

85 S UNION BLVD APT 514
DENVER CO
80228-2289
US

V. Phone/Fax

Practice location:
  • Phone: 320-202-8949
  • Fax: 320-257-1733
Mailing address:
  • Phone: 206-551-7626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12813
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: