Healthcare Provider Details

I. General information

NPI: 1225816366
Provider Name (Legal Business Name): ALEXANDRA SMITH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 CHURCHMAN AVE
BEECH GROVE IN
46107-1044
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 317-786-9285
  • Fax: 317-781-2109
Mailing address:
  • Phone: 317-528-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004183A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: