Provider Demographics
NPI:1407146509
Name:SLAGLE, ELIZABETH AMANDA (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:AMANDA
Last Name:SLAGLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WABASHA ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-1805
Mailing Address - Country:US
Mailing Address - Phone:651-293-8100
Mailing Address - Fax:
Practice Address - Street 1:205 WABASHA ST S
Practice Address - Street 2:MMC 207
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-1805
Practice Address - Country:US
Practice Address - Phone:651-293-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN108235207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program