Healthcare Provider Details

I. General information

NPI: 1134831605
Provider Name (Legal Business Name): ALIYAH PATTERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12700 SOUTHFORK RD STE 100
SAINT LOUIS MO
63128-3201
US

IV. Provider business mailing address

12700 SOUTHFORK RD STE 100
SAINT LOUIS MO
63128-3201
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5284
  • Fax:
Mailing address:
  • Phone: 314-543-5284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00747900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2023040454
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: