Provider Demographics
NPI:1154380871
Name:WIBORG, ELIZABETH A (RN CNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:WIBORG
Suffix:
Gender:F
Credentials:RN CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7755 CENTER AVE
Mailing Address - Street 2:STE 630
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-9152
Mailing Address - Country:US
Mailing Address - Phone:657-400-5180
Mailing Address - Fax:
Practice Address - Street 1:2450 26TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-1245
Practice Address - Country:US
Practice Address - Phone:612-721-2491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 94784-6363LG0600X
MNCNP 2753363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN504536600Medicaid
MN504536600Medicaid