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General NPI Number Information
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NPI Number | 1902456817
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Entity Type | Individual
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Provider Name | MADELINE KATE LIEBERSON
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Gender | Female
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Dates
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Enumeration Date | 09/13/2019
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Last Update Date | 05/20/2024
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Provider Practice Location Address
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Address Line | 1811 WEIR DR STE 270
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City | WOODBURY
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State | MN
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Zip | 55125-6741
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Country | US
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Telephone | 651-243-6072
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Fax | 651-714-9647
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Provider Business Mailing Address
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Address Line | 9637 OLIVE LN N
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City | MAPLE GROVE
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State | MN
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Zip | 55311-4531
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Country | US
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Telephone | 763-438-2190
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 13134
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License Number State | MN
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