Healthcare Provider Details

I. General information

NPI: 1629370754
Provider Name (Legal Business Name): ALEXANDRA ARD VAUGHAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXANDRA MARIE ARD PA-C

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 07/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10666 N TORREY PINES RD
LA JOLLA CA
92037-1027
US

IV. Provider business mailing address

10170 SORRENTO VALLEY RD MAIL DROP SV-5
SAN DIEGO CA
92121-1604
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-4310
  • Fax:
Mailing address:
  • Phone: 858-784-5888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA21317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: