Healthcare Provider Details

I. General information

NPI: 1821416926
Provider Name (Legal Business Name): ELAINE MAE SVOBODA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELAINE SVOBODA HAMMOND

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8373 UNITY DR
VIRGINIA MN
55792-4005
US

IV. Provider business mailing address

8373 UNITY DR
VIRGINIA MN
55792-4005
US

V. Phone/Fax

Practice location:
  • Phone: 218-748-7480
  • Fax: 218-748-7488
Mailing address:
  • Phone: 218-748-7480
  • Fax: 218-748-7488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11642
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: