Provider Demographics
NPI:1235305483
Name:TANAKA, ELISA MARI (DO)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:MARI
Last Name:TANAKA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ELISA
Other - Middle Name:MARI
Other - Last Name:TANAKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ELISA MARI HANSEN DO
Mailing Address - Street 1:14700 28TH AVE N STE 20
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4876
Mailing Address - Country:US
Mailing Address - Phone:763-852-0411
Mailing Address - Fax:
Practice Address - Street 1:14700 28TH AVE N STE 20
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55447-4876
Practice Address - Country:US
Practice Address - Phone:763-852-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN53903207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN20394OtherRESIDENT PERMIT