Provider Demographics
NPI:1629707849
Name:BENGTSON, EMMA B (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:B
Last Name:BENGTSON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 US HIGHWAY 59
Mailing Address - Street 2:
Mailing Address - City:GARVIN
Mailing Address - State:MN
Mailing Address - Zip Code:56132-1161
Mailing Address - Country:US
Mailing Address - Phone:402-871-0617
Mailing Address - Fax:
Practice Address - Street 1:1521 CARLSON ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2626
Practice Address - Country:US
Practice Address - Phone:507-476-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant