MEDICARE: ALEXANDRA LYNN LIETHEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1508754979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA LYNN LIETHEN

Provider Business Mailing Address
First Line	:	11050 CEDAR HILLS BLVD APT 323
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55305-3057
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9645 GROVE CIR N STE 100
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-2682
Country	:	US
Telephone Number	:	763-302-4114
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2025
Last Update Date	:	06/25/2025

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Directions to “ ALEXANDRA LYNN LIETHEN ” Practice Location

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