Provider Demographics
NPI:1376312827
Name:MUDRAYA, ELLINA ANDREYEVNA (PTA)
Entity Type:Individual
Prefix:
First Name:ELLINA
Middle Name:ANDREYEVNA
Last Name:MUDRAYA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15260 BARIUM ST NW
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-5986
Mailing Address - Country:US
Mailing Address - Phone:763-227-4542
Mailing Address - Fax:
Practice Address - Street 1:5430 BOONE AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3615
Practice Address - Country:US
Practice Address - Phone:763-592-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2941225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant