Provider Demographics
NPI:1558025270
Name:JEAN, ALIX DANIEL
Entity Type:Individual
Prefix:
First Name:ALIX
Middle Name:DANIEL
Last Name:JEAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 N COL ROWE BLVD APT 110
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-2201
Mailing Address - Country:US
Mailing Address - Phone:956-223-9695
Mailing Address - Fax:
Practice Address - Street 1:1901 N COL ROWE BLVD APT 110
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-2201
Practice Address - Country:US
Practice Address - Phone:956-223-9695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1038-P.A.363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty