Provider Demographics
NPI:1689104986
Name:BACKER, ELLIOT DANIEL (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:DANIEL
Last Name:BACKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CARLSON PKWY N STE 240
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4485
Mailing Address - Country:US
Mailing Address - Phone:763-367-7110
Mailing Address - Fax:
Practice Address - Street 1:6425 NICOLLET AVE STE 202
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1668
Practice Address - Country:US
Practice Address - Phone:612-869-2086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12466207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology