Provider Demographics
NPI:1275853459
Name:MORE, ALYSA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSA
Middle Name:
Last Name:MORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALYSA
Other - Middle Name:
Other - Last Name:STAFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3833 COON RAPIDS BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2697
Mailing Address - Country:US
Mailing Address - Phone:763-427-8320
Mailing Address - Fax:763-302-4338
Practice Address - Street 1:3833 COON RAPIDS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2697
Practice Address - Country:US
Practice Address - Phone:763-427-8320
Practice Address - Fax:763-302-4338
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10819363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1092837OtherNCCPA