Provider Demographics
NPI:1649886375
Name:BALSTER, ALICIA TERESE (PA-C)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:TERESE
Last Name:BALSTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:TERESE
Other - Last Name:ICKSTADT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3580 ARCADE ST. SOUTH
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55127
Mailing Address - Country:US
Mailing Address - Phone:651-968-5461
Mailing Address - Fax:651-730-3722
Practice Address - Street 1:3580 ARCADE STREET SOUTH
Practice Address - Street 2:
Practice Address - City:VADNAIS HIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127
Practice Address - Country:US
Practice Address - Phone:651-968-5461
Practice Address - Fax:651-730-3722
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant