Provider Demographics
NPI:1427711183
Name:THELEN, ELIZABETH KAY (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KAY
Last Name:THELEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:KAY
Other - Last Name:LASTOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:
Practice Address - Street 1:8540 QUADAY AVE NE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-6522
Practice Address - Country:US
Practice Address - Phone:763-441-0298
Practice Address - Fax:763-441-0591
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13872363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant