Healthcare Provider Details

I. General information

NPI: 1659923555
Provider Name (Legal Business Name): ALEXANDRA CARLISLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXANDRA SMITH

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 E MAYO BLVD
PHOENIX AZ
85054-4502
US

IV. Provider business mailing address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5452
US

V. Phone/Fax

Practice location:
  • Phone: 480-342-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7540
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: