Healthcare Provider Details

I. General information

NPI: 1831903780
Provider Name (Legal Business Name): ALEXA GRACE AUGUSTINE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2025
Last Update Date: 02/03/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5133 N CENTRAL AVE STE 206
PHOENIX AZ
85012-1438
US

IV. Provider business mailing address

5133 N CENTRAL AVE
PHOENIX AZ
85012-1438
US

V. Phone/Fax

Practice location:
  • Phone: 602-264-0608
  • Fax:
Mailing address:
  • Phone: 602-264-0608
  • Fax: 602-234-0417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10962
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: