Provider Demographics
NPI:1629184320
Name:LIEBENOW, RACHEL L (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:L
Last Name:LIEBENOW
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 1:500 SOUTH MAPLE STREET
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387
Mailing Address - Country:US
Mailing Address - Phone:952-442-2191
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:500 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1752
Practice Address - Country:US
Practice Address - Phone:952-442-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970002763Medicare PIN
S74428Medicare UPIN
MN970002763Medicare ID - Type Unspecified