Healthcare Provider Details

I. General information

NPI: 1710726948
Provider Name (Legal Business Name): ALEXANDRA DEROSA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 STUART ST STE 404
BOSTON MA
02116-5019
US

IV. Provider business mailing address

441 STUART ST STE 404
BOSTON MA
02116-5019
US

V. Phone/Fax

Practice location:
  • Phone: 857-317-2057
  • Fax: 857-317-2811
Mailing address:
  • Phone: 857-317-2057
  • Fax: 857-317-2811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA102136
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: