Provider Demographics
NPI:1578291472
Name:KILLINO, ALEXIS LOUISE (PA)
Entity Type:Individual
Prefix:MS
First Name:ALEXIS
Middle Name:LOUISE
Last Name:KILLINO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 US HIGHWAY 22 STE 2023
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-2950
Mailing Address - Country:US
Mailing Address - Phone:908-756-2424
Mailing Address - Fax:
Practice Address - Street 1:454 ELIZABETH AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-5111
Practice Address - Country:US
Practice Address - Phone:908-756-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008759363A00000X
363A00000X
NJ25MP00807800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1578291472Medicaid
VA30017507230001Medicaid