Provider Demographics
NPI:1750320487
Name:BOYUM, ELIZABETH N (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:N
Last Name:BOYUM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 SPRINGER DR
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6413
Mailing Address - Country:US
Mailing Address - Phone:815-744-8554
Mailing Address - Fax:
Practice Address - Street 1:23505 SMITHTOWN RD STE 120
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-4542
Practice Address - Country:US
Practice Address - Phone:612-486-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
507S6NEOtherBCBS
HP36291OtherPARTNERS HEALTH
1041654OtherPREFERRED ONE
1041654OtherPREFERRED ONE
HP36291OtherPARTNERS HEALTH
P84553Medicare UPIN
970001578Medicare PIN
CS6766Medicare PIN