Healthcare Provider Details

I. General information

NPI: 1902373095
Provider Name (Legal Business Name): ALEXANDRA L BOURCY-CRANDELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2018
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 HIGHWAY 45 N
COLUMBUS MS
39705-2113
US

IV. Provider business mailing address

29 FRIAR TUCK CIR
COLUMBUS MS
39705-3012
US

V. Phone/Fax

Practice location:
  • Phone: 662-328-9623
  • Fax:
Mailing address:
  • Phone: 585-698-0967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA56628
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA56628
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA56628
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00673
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: