Healthcare Provider Details

I. General information

NPI: 1033606157
Provider Name (Legal Business Name): BROOKE ALEXANDRA KUTZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BROOKE ALEXANDRA JENSEN MD

II. Dates (important events)

Enumeration Date: 04/14/2018
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 MARYLAND AVE E
SAINT PAUL MN
55106-2824
US

IV. Provider business mailing address

10689 SONOMA RDG
EDEN PRAIRIE MN
55347-1169
US

V. Phone/Fax

Practice location:
  • Phone: 651-772-3461
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number68573
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: