Healthcare Provider Details

I. General information

NPI: 1073362455
Provider Name (Legal Business Name): ALEXANDREA MARIE KOWALKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2024
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1350
US

IV. Provider business mailing address

PO BOX 170
HOWARD LAKE MN
55349-0170
US

V. Phone/Fax

Practice location:
  • Phone: 763-273-0177
  • Fax:
Mailing address:
  • Phone: 763-273-0177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: