Provider Demographics
NPI:1578024527
Name:PROVAGNA, ALYSSA J (MD)
Entity Type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:J
Last Name:PROVAGNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4430 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-9098
Mailing Address - Country:US
Mailing Address - Phone:573-596-1770
Mailing Address - Fax:
Practice Address - Street 1:4430 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9098
Practice Address - Country:US
Practice Address - Phone:573-596-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-30
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010127064208D00000X
VA0101270674207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice