Provider Demographics
NPI:1528583481
Name:BANGASSER, ALEXANDRA KATHLEEN (PT)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:KATHLEEN
Last Name:BANGASSER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20417 PINTAIL CT
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-8783
Mailing Address - Country:US
Mailing Address - Phone:763-516-2152
Mailing Address - Fax:
Practice Address - Street 1:500 PARK ST E
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:MN
Practice Address - Zip Code:55302-3060
Practice Address - Country:US
Practice Address - Phone:320-274-2394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10792225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist