=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538824156
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXANDRA CONWAY MS, LAT, ATC, EMT-B
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2021
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 W OLNEY AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19141-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-951-1519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6204 AVENEL BLVD
-----------------------------------------------------
City | NORTH WALES
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19454-3959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-716-0593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | RT008192
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 146N00000X
-----------------------------------------------------
Taxonomy Name | Basic Emergency Medical Technician
-----------------------------------------------------
License Number | 0912212
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------