Provider Demographics
NPI:1699437145
Name:ABRAHAM, ELIZA ANDERSON (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:ANDERSON
Last Name:ABRAHAM
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 1:4480 CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55127
Mailing Address - Country:US
Mailing Address - Phone:651-484-2724
Mailing Address - Fax:651-484-2723
Practice Address - Street 1:4480 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55127
Practice Address - Country:US
Practice Address - Phone:651-484-2724
Practice Address - Fax:651-484-2723
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14153363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN14153OtherMN LICENSE