Healthcare Provider Details

I. General information

NPI: 1497128722
Provider Name (Legal Business Name): ALEXANDRA BLUE SANROMA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXANDRA BLUE GONZALEZ PA-C

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S UNIVERSITY AVE LITTLE ROCK DERMATOLOGY CLINIC SUITE 301
LITTLE ROCK AR
72205-5302
US

IV. Provider business mailing address

500 S UNIVERSITY AVE LITTLE ROCK DERMATOLOGY CLINIC SUITE 301
LITTLE ROCK AR
72205-5302
US

V. Phone/Fax

Practice location:
  • Phone: 501-664-4161
  • Fax: 501-664-6108
Mailing address:
  • Phone: 501-664-4161
  • Fax: 501-664-6108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberP-T1551
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: