Basic Information
| Provider Information | |||||||||
| NPI: | 1154380871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIBORG | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | RN CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7755 CENTER AVE | ||||||||
| Address2: | STE 630 | ||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926479152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6574005180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2450 26TH AVE S | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554061245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127212491 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | R 94784-6 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LG0600X | CNP 2753 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 504536600 | 05 | MN | MEDICAID |