Healthcare Provider Details

I. General information

NPI: 1982975454
Provider Name (Legal Business Name): ALEXIS BROOKE MINCER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2012
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9908 ROOSEVELT BLVD
PHILADELPHIA PA
19115
US

IV. Provider business mailing address

1390 REVELATION RD
JENKINTOWN PA
19046-1022
US

V. Phone/Fax

Practice location:
  • Phone: 215-464-2902
  • Fax: 215-464-2954
Mailing address:
  • Phone: 610-203-3387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA056041
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberOA006847
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: