MEDICARE: BROOKE LEIGH ELVEHJEM PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	13897	MN

General Provider Information

NPI Number	:	1174281034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE LEIGH ELVEHJEM PA-C

Provider Business Mailing Address
First Line	:	4480 CENTERVILLE RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55127-3674
Country	:	US
Telephone Number	:	651-484-2724
Fax Number	:

Provider Business Practice Location Address
First Line	:	4480 CENTERVILLE RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55127-3674
Country	:	US
Telephone Number	:	651-484-2724
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2021
Last Update Date	:	03/04/2022

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