Provider Demographics
NPI:1124286901
Name:RADKE, ELIZABETH ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:RADKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13599 QUENTIN AVE S
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-1814
Mailing Address - Country:US
Mailing Address - Phone:612-220-1891
Mailing Address - Fax:
Practice Address - Street 1:500 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1752
Practice Address - Country:US
Practice Address - Phone:952-442-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1128363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00711751Medicare PIN
MN970003998Medicare PIN