Provider Demographics
NPI:1114533874
Name:MCCOMB, ALEXIS (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:MCCOMB
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 HOUSEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12037-1400
Mailing Address - Country:US
Mailing Address - Phone:518-653-1555
Mailing Address - Fax:
Practice Address - Street 1:2 SHERMAN POTTS DR
Practice Address - Street 2:
Practice Address - City:GHENT
Practice Address - State:NY
Practice Address - Zip Code:12075-3216
Practice Address - Country:US
Practice Address - Phone:518-392-2277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant