Provider Demographics
NPI:1053831487
Name:DISRUD, ALEXANDRA DENISE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:DENISE
Last Name:DISRUD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:DENISE
Other - Last Name:DE VRIES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:36500 AURORA DR
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4899
Mailing Address - Country:US
Mailing Address - Phone:262-434-1000
Mailing Address - Fax:262-434-5050
Practice Address - Street 1:36500 AURORA DR
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:WI
Practice Address - Zip Code:53066
Practice Address - Country:US
Practice Address - Phone:262-434-1000
Practice Address - Fax:262-434-5050
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1053831487Medicaid