Provider Demographics
NPI:1407892672
Name:BLACKMON, ALEXANDRIA DENISE (NP)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:DENISE
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE STREET SE, MMC 195
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-625-1400
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - Street 2:516 DELAWARE STREET SE, PWB FIRST FLOOR, CLINIC 1E
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-626-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 146110-1363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2386128OtherARAZ
IA0599241Medicaid
MN083447500Medicaid
MN135259OtherUCARE
MT4307035Medicaid
MNHP56036OtherHEALTHPARTNERS
MN04-07907OtherMEDICA CHOICE & PRIMARY
MNB678OtherCHAMPUS/TRIWEST
MN500003192Medicare ID - Type UnspecifiedMN MEDICARE
MNQ55338Medicare UPIN