Healthcare Provider Details

I. General information

NPI: 1952754764
Provider Name (Legal Business Name): ALEXANDRA GIANOLI PA-C, MMS,ATC-L, MAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2016
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 112A
SAINT LOUIS MO
63141-8252
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6339
  • Fax:
Mailing address:
  • Phone: 314-251-6339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3540
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2021024746
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL2885
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: