Healthcare Provider Details

I. General information

NPI: 1588220867
Provider Name (Legal Business Name): ALEXA JESSE MIESBAUER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXA JESSE EDMAN PT, DPT

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2090 WOODWINDS DR STE 100
WOODBURY MN
55125-2522
US

IV. Provider business mailing address

709 VICTORIA ST S
SAINT PAUL MN
55102-3169
US

V. Phone/Fax

Practice location:
  • Phone: 651-968-5600
  • Fax: 651-968-5898
Mailing address:
  • Phone: 605-280-8016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10112
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: