Provider Demographics
NPI:1326515784
Name:BERICHON, ALEXANDRA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:BERICHON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-9743
Mailing Address - Country:US
Mailing Address - Phone:517-945-8298
Mailing Address - Fax:
Practice Address - Street 1:153 WAMPLERS LAKE RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-9585
Practice Address - Country:US
Practice Address - Phone:517-205-2105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008849363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant