Provider Demographics
NPI:1134534282
Name:GRUSE, EMILEE JEANNE (PAC, ATC, LAT)
Entity type:Individual
Prefix:
First Name:EMILEE
Middle Name:JEANNE
Last Name:GRUSE
Suffix:
Gender:F
Credentials:PAC, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 PREMIER DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6076
Mailing Address - Country:US
Mailing Address - Phone:507-386-6600
Mailing Address - Fax:507-386-0252
Practice Address - Street 1:744 MICKELSON TRL
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-1503
Practice Address - Country:US
Practice Address - Phone:765-423-6888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-27
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001767A2255A2300X
MN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty