Provider Demographics
NPI:1346058971
Name:YANG, ALISA
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:YANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 BELT LINE BLVD APT 208
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2607
Mailing Address - Country:US
Mailing Address - Phone:763-339-8007
Mailing Address - Fax:
Practice Address - Street 1:790 S PLAZA DR STE 100
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120-1802
Practice Address - Country:US
Practice Address - Phone:763-339-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2024-227225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty