Provider Demographics
NPI:1073124590
Name:MILLER, ALEXANDRA JEAN (PA)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:JEAN
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:
Other - Last Name:WALKUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-892-6401
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:1860 E EGBERT ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-2404
Practice Address - Country:US
Practice Address - Phone:303-697-2583
Practice Address - Fax:303-655-4924
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000184561Medicaid