Provider Demographics
NPI:1700288818
Name:ELLIAS, KIMBERLY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:ELLIAS
Suffix:
Gender:F
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 1:6331 CHEROKEE TRL
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55038-9140
Mailing Address - Country:US
Mailing Address - Phone:218-343-2806
Mailing Address - Fax:
Practice Address - Street 1:1515 COUNTY ROAD B W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-6005
Practice Address - Country:US
Practice Address - Phone:651-631-0330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant