Provider Demographics
NPI:1154888113
Name:GHYLIN, ABIGAIL RAYNA (PA-S)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:RAYNA
Last Name:GHYLIN
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 COUNTY ROAD D E STE C100
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5354
Mailing Address - Country:US
Mailing Address - Phone:651-358-7020
Mailing Address - Fax:
Practice Address - Street 1:15650 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7283
Practice Address - Country:US
Practice Address - Phone:952-997-4100
Practice Address - Fax:952-997-4102
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN133372084P0800X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty