Provider Demographics
NPI:1750320487
Name:BOYUM, ELIZABETH N (PA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:N
Last Name:BOYUM
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14305 SOUTHCROSS DR W STE 110
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-7011
Mailing Address - Country:US
Mailing Address - Phone:651-340-1064
Mailing Address - Fax:
Practice Address - Street 1:14305 SOUTHCROSS DR W STE 110
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-7011
Practice Address - Country:US
Practice Address - Phone:513-401-0646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2025-04-22
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
1041654OtherPREFERRED ONE
507S6NEOtherBCBS
HP36291OtherPARTNERS HEALTH
1041654OtherPREFERRED ONE
HP36291OtherPARTNERS HEALTH
P84553Medicare UPIN
970001578Medicare PIN
CS6766Medicare PIN