Healthcare Provider Details

I. General information

NPI: 1609451210
Provider Name (Legal Business Name): ALEXA FRANCES WILLARD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXA FRANCES THIELMAN PA-C

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 BRADDOCK AVE NE STE 400
BUFFALO MN
55313-3681
US

IV. Provider business mailing address

3650 BRADDOCK AVE NE STE 400
BUFFALO MN
55313-3681
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-4725
  • Fax: 952-883-9604
Mailing address:
  • Phone: 763-587-4725
  • Fax: 952-883-9604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15406
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMED-PAC-LIC-95816
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: