Basic Information
| Provider Information | |||||||||
| NPI: | 1457479495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLINGSON | ||||||||
| FirstName: | BETSY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14909 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554140909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711145 | ||||||||
| FaxNumber: | 6128705491 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 BROADWAY ST NE STE 500 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554132197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1287111456 | ||||||||
| FaxNumber: | 6128705491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 040060 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 357842900 | 05 | MN | MEDICAID |