Provider Demographics
NPI:1871240168
Name:ABBOTT, ELISE MARIE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:MARIE
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 WHITE BEAR AVE N STE 104
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-4568
Mailing Address - Country:US
Mailing Address - Phone:612-444-3247
Mailing Address - Fax:612-888-9247
Practice Address - Street 1:2480 WHITE BEAR AVE N STE 104
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-4568
Practice Address - Country:US
Practice Address - Phone:612-444-3247
Practice Address - Fax:612-888-9247
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14184363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty