Healthcare Provider Details

I. General information

NPI: 1497460836
Provider Name (Legal Business Name): ALEXANDRA ANN DALLO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2023
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE RD
TROY MI
48085-1117
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-964-5000
  • Fax:
Mailing address:
  • Phone: 947-522-1865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011576
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: