Healthcare Provider Details

I. General information

NPI: 1659846483
Provider Name (Legal Business Name): ALEXANDRA MICHELE KUIZENGA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 E NORTH ST
MANTECA CA
95336-4932
US

IV. Provider business mailing address

PO BOX 1986
BENICIA CA
94510-4986
US

V. Phone/Fax

Practice location:
  • Phone: 209-823-3111
  • Fax:
Mailing address:
  • Phone: 707-334-3265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56103
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: