Healthcare Provider Details

I. General information

NPI: 1952867731
Provider Name (Legal Business Name): ALEXA EVIE NACEANCENO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2019
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 BELLEVUE AVE STE 300
SAINT LOUIS MO
63117-1857
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 314-647-9444
  • Fax: 314-647-7317
Mailing address:
  • Phone: 314-851-1000
  • Fax: 314-851-4477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.007574
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2020007934
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: