Healthcare Provider Details

I. General information

NPI: 1265104764
Provider Name (Legal Business Name): ALEXANDER MARCEL LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2021
Last Update Date: 11/10/2024
Certification Date: 11/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11850 BLACKFOOT ST NW STE 490
COON RAPIDS MN
55433-2773
US

IV. Provider business mailing address

11850 BLACKFOOT ST NW STE 490
COON RAPIDS MN
55433-2773
US

V. Phone/Fax

Practice location:
  • Phone: 763-427-1137
  • Fax:
Mailing address:
  • Phone: 612-871-7278
  • Fax: 612-863-8531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number13862
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13862
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: