Basic Information
| Provider Information | |||||||||
| NPI: | 1093335796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVERSON | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540244117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833261 | ||||||||
| FaxNumber: | 7154830507 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540244117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833261 | ||||||||
| FaxNumber: | 7154830507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2020 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5056 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 13348 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.