Provider Demographics
NPI:1508893561
Name:ELKO, STEPHANIE P (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:P
Last Name:ELKO
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:P
Other - Last Name:FAUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPAS, PA-C
Mailing Address - Street 1:267 ROMA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6723
Mailing Address - Country:US
Mailing Address - Phone:612-236-7396
Mailing Address - Fax:
Practice Address - Street 1:2265 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1737
Practice Address - Country:US
Practice Address - Phone:888-364-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10118363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN694183400Medicaid
MN694183400Medicaid
MNRR PTAN P00368965Medicare PIN
MN970002680Medicare PIN