Provider Demographics
NPI:1255660452
Name:BOLICK, ALEXIS A (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:A
Last Name:BOLICK
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 1:9645 GROVE CIR N STE 200
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4466
Mailing Address - Country:US
Mailing Address - Phone:763-201-8191
Mailing Address - Fax:763-201-8192
Practice Address - Street 1:9645 GROVE CIR N STE 200
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:763-201-8191
Practice Address - Fax:763-201-8192
Is Sole Proprietor?:No
Enumeration Date:2009-12-17
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN10652363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant