Basic Information
| Provider Information | |||||||||
| NPI: | 1437803848 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOELE | ||||||||
| FirstName: | ELISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3315 53RD AVE N APT 203 | ||||||||
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| City: | BROOKLYN CENTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554293444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153381448 | ||||||||
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| Practice Location | |||||||||
| Address1: | 640 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551012595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512543456 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2022 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.