Provider Demographics
NPI:1578394748
Name:NORDSTROM, ALEX
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:NORDSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 SIBLEY MEMORIAL HWY APT 240
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-5601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6550 YORK AVE S STE 317
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2334
Practice Address - Country:US
Practice Address - Phone:612-499-5946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13652225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist