Provider Demographics
NPI:1417503558
Name:KOES, ALEXANDRA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:KOES
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:55369-2684
Mailing Address - Country:US
Mailing Address - Phone:763-201-8191
Mailing Address - Fax:
Practice Address - Street 1:9645 GROVE CIR N STE 250
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-2683
Practice Address - Country:US
Practice Address - Phone:763-201-8191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13496363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant