Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | 275 | MN |
N | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 275 | MN |
NPI | 1164419644 |
---|---|
Provider Name | Elisa M Smith |
First Address | Minneapolis, MN 55407-1321 |
Second Address | Minneapolis, MN 55407-1321 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/09/2005 |
Last Update Date | 08/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0423194 | (05) | IA |
55721 | WELLMARK BCBS (01) | IA |
P64425 | (02) |