Healthcare Provider Details

I. General information

NPI: 1588298103
Provider Name (Legal Business Name): ALEXANDRA WILSON MPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

18333 EGRET BAY BLVD STE 200
HOUSTON TX
77058-3200
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-8275
  • Fax:
Mailing address:
  • Phone: 281-333-1300
  • Fax: 281-333-1303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13121
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: