Provider Demographics
NPI:1306434337
Name:PROVOST, ALEXANDER ANTON (DC)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:ANTON
Last Name:PROVOST
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8732 POLK ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-2346
Mailing Address - Country:US
Mailing Address - Phone:763-439-6576
Mailing Address - Fax:
Practice Address - Street 1:W5675 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-6901
Practice Address - Country:US
Practice Address - Phone:715-526-6158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6646111N00000X
WI5599-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor