Provider Demographics
NPI:1902988421
Name:MACIEJ, ALEXIS RUPP (PNP)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:RUPP
Last Name:MACIEJ
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:420 DELAWARE STREET SE MMC 484
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-625-5411
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-672-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 146818-8363LP0200X
MN1138363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0599746Medicaid
2393329OtherARAZ
135386OtherUCARE
WI41270300Medicaid
B675OtherTRICARE/TRIWEST
1046051OtherPREFERREDONE
12-09026OtherMEDICAID PRIMARY
MN994940200Medicaid
12-03425OtherMEDICA - CHOICE
MT4306627Medicaid
MNHP56959OtherHEALTHPARTNERS
MN631T4MAOtherBLUE CROSS BLUE SHIELD
1046051OtherPREFERREDONE
Q60880Medicare UPIN