Basic Information
| Provider Information | |||||||||
| NPI: | 1750320487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYUM | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 SPRINGER DR | ||||||||
| Address2: | |||||||||
| City: | LOMBARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601486413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157448554 | ||||||||
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| Practice Location | |||||||||
| Address1: | 23505 SMITHTOWN RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | EXCELSIOR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553314542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6124864200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9778 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 507S6NE | 01 | BCBS | OTHER | HP36291 | 01 | PARTNERS HEALTH | OTHER | 1041654 | 01 | PREFERRED ONE | OTHER |