Healthcare Provider Details

I. General information

NPI: 1750171708
Provider Name (Legal Business Name): ALEXA SANSON MSPAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 07/01/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

863 N MAIN STREET EXT STE 200
WALLINGFORD CT
06492-2434
US

IV. Provider business mailing address

863 N MAIN STREET EXT STE 200
WALLINGFORD CT
06492-2434
US

V. Phone/Fax

Practice location:
  • Phone: 203-265-3280
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7125
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: