Provider Demographics
NPI:1093335796
Name:EVERSON, ALYSSA ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ROSE
Last Name:EVERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E NICOLLET BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-6772
Mailing Address - Country:US
Mailing Address - Phone:952-435-8516
Mailing Address - Fax:763-302-4336
Practice Address - Street 1:501 E NICOLLET BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6772
Practice Address - Country:US
Practice Address - Phone:952-435-8516
Practice Address - Fax:763-302-4336
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5056363A00000X
MN13348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant