Provider Demographics
NPI:1407446784
Name:SHORT, ALEXANDRA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:SHORT
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 1:1867 WATER OAK WAY
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7421
Mailing Address - Country:US
Mailing Address - Phone:463-201-7944
Mailing Address - Fax:
Practice Address - Street 1:931 E 86TH ST STE 104
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1852
Practice Address - Country:US
Practice Address - Phone:317-257-1484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003595A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant