Provider Demographics
NPI:1669452074
Name:LUSSENHOP, ANTHONY P (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:P
Last Name:LUSSENHOP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 30TH AVE W
Mailing Address - Street 2:ALEXANDRIA CLINIC
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308
Mailing Address - Country:US
Mailing Address - Phone:320-763-5123
Mailing Address - Fax:320-763-7883
Practice Address - Street 1:610 30TH AVE W
Practice Address - Street 2:ALEXANDRIA CLINIC
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308
Practice Address - Country:US
Practice Address - Phone:320-763-5123
Practice Address - Fax:320-763-7883
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN713063500Medicaid
MN080105723OtherRR MEDICARE
F32164Medicare UPIN
MN080022719Medicare PIN
MN713063500Medicaid