Healthcare Provider Details

I. General information

NPI: 1518685379
Provider Name (Legal Business Name): ALEX BLOOMQUIST PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HUNDERTMARK RD STE 220
CHASKA MN
55318-1197
US

IV. Provider business mailing address

111 HUNDERTMARK RD STE 220
CHASKA MN
55318-1197
US

V. Phone/Fax

Practice location:
  • Phone: 952-856-4001
  • Fax: 952-443-4875
Mailing address:
  • Phone: 952-856-4001
  • Fax: 952-443-4875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15045
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: