Healthcare Provider Details

I. General information

NPI: 1013884691
Provider Name (Legal Business Name): EMMAH KAYE GRISWOLD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2025
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4480 CENTERVILLE RD
WHITE BEAR LAKE MN
55127-3674
US

IV. Provider business mailing address

4480 CENTERVILLE RD
WHITE BEAR LAKE MN
55127-3674
US

V. Phone/Fax

Practice location:
  • Phone: 651-484-2724
  • Fax:
Mailing address:
  • Phone: 651-484-2724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15521
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: