Healthcare Provider Details

I. General information

NPI: 1629184320
Provider Name (Legal Business Name): RACHEL L LIEBENOW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S MAPLE ST
WACONIA MN
55387-1752
US

IV. Provider business mailing address

500 SOUTH MAPLE STREET
WACONIA MN
55387
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-2191
  • Fax:
Mailing address:
  • Phone: 952-442-2191
  • Fax: 651-968-5904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8908
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: