Provider Demographics
NPI:1093228520
Name:GRAND, ALEXA BLAIRE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:BLAIRE
Last Name:GRAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALEXA
Other - Middle Name:BLAIRE
Other - Last Name:VESSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:500 S 52ND ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8600
Mailing Address - Country:US
Mailing Address - Phone:479-254-9662
Mailing Address - Fax:479-254-9662
Practice Address - Street 1:500 S 52ND ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8600
Practice Address - Country:US
Practice Address - Phone:479-254-9662
Practice Address - Fax:806-701-5845
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-922363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant