Provider Demographics
NPI:1689186207
Name:MALKUCH, ALEXANDRA (CRNA)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:MALKUCH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 LAKE AVE N
Mailing Address - Street 2:
Mailing Address - City:SPICER
Mailing Address - State:MN
Mailing Address - Zip Code:56288-9616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 BECKER AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3302
Practice Address - Country:US
Practice Address - Phone:320-253-4543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-05
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10167363L00000X
390200000X
MN120311367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program