Provider Demographics
NPI:1497407043
Name:PETERSON, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5208 MONROVIA HEIGHTS ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-2957
Mailing Address - Country:US
Mailing Address - Phone:702-575-8819
Mailing Address - Fax:
Practice Address - Street 1:5208 MONROVIA HEIGHTS ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-2957
Practice Address - Country:US
Practice Address - Phone:702-575-8819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist