Basic Information
Provider Information | |||||||||
NPI: | 1487612164 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KHARBANDA | ||||||||
FirstName: | ELYSE | ||||||||
MiddleName: | O | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8170 33RD AVE S | ||||||||
Address2: | MS21110Q | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554254516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528835375 | ||||||||
FaxNumber: | 6517025305 | ||||||||
Practice Location | |||||||||
Address1: | 8450 SEASONS PKWY - MAIL STOP 32900A | ||||||||
Address2: | HEALTHPARTNERS WOODBURY CLINIC | ||||||||
City: | WOODBURY | ||||||||
State: | MN | ||||||||
PostalCode: | 551254402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6517025300 | ||||||||
FaxNumber: | 6517025305 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 12/08/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 105050 | MN | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 105050 | 01 | MN | MN MEDICAL LICENSE (TEMPORARY) | OTHER | BO7215355 | 01 | MN | MN DEA | OTHER |