Provider Demographics
NPI:1508421280
Name:ALEXANDER, ANTWAIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANTWAIN
Middle Name:
Last Name:ALEXANDER
Suffix:
Gender:M
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 1:3505 W EL CABRIO DR
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-6710
Mailing Address - Country:US
Mailing Address - Phone:719-406-1868
Mailing Address - Fax:
Practice Address - Street 1:3505 W EL CABRIO DR
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-6710
Practice Address - Country:US
Practice Address - Phone:719-406-1868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005769363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant