Provider Demographics
NPI:1497103485
Name:PAVLIDES, ALEXANDROS JOHN
Entity Type:Individual
Prefix:MR
First Name:ALEXANDROS
Middle Name:JOHN
Last Name:PAVLIDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ALEXANDROS
Other - Middle Name:JOHN
Other - Last Name:PAVLIDES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:ORDERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84758-0236
Mailing Address - Country:US
Mailing Address - Phone:909-725-6271
Mailing Address - Fax:
Practice Address - Street 1:640 E 700 S STE 3
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-4006
Practice Address - Country:US
Practice Address - Phone:435-673-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11799232-1206363AM0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTXXXMedicaid