Healthcare Provider Details

I. General information

NPI: 1568820199
Provider Name (Legal Business Name): ALEXA BOERSEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9576 HWY 70
MINOCQUA WI
54548-9067
US

IV. Provider business mailing address

833 MICHIGAN ST NE BLDG 102
GRAND RAPIDS MI
49503-2578
US

V. Phone/Fax

Practice location:
  • Phone: 715-358-1000
  • Fax:
Mailing address:
  • Phone: 616-459-8209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4631
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4631
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007612
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: