Provider Demographics
NPI:1639707250
Name:NYBERG, KATELYNN MAE (PA-C)
Entity type:Individual
Prefix:
First Name:KATELYNN
Middle Name:MAE
Last Name:NYBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12000 ELM CREEK BLVD N STE L70
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7167
Mailing Address - Country:US
Mailing Address - Phone:524-315-3309
Mailing Address - Fax:952-431-5334
Practice Address - Street 1:12000 ELM CREEK BLVD N STE L70
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7167
Practice Address - Country:US
Practice Address - Phone:952-431-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN13511363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant