Healthcare Provider Details

I. General information

NPI: 1114514916
Provider Name (Legal Business Name): ALEXANDRA MARTINEZ YACANO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 01/15/2024
Certification Date: 01/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PLEASANT ST
CONCORD NH
03301-7559
US

IV. Provider business mailing address

11 KIMBALL DR UNIT 125
HOOKSETT NH
03106-2623
US

V. Phone/Fax

Practice location:
  • Phone: 603-314-6879
  • Fax:
Mailing address:
  • Phone: 603-314-6879
  • Fax: 603-622-7438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: