Provider Demographics
NPI:1609501550
Name:REEDER, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:REEDER
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 1:17800 112TH AVE
Mailing Address - Street 2:
Mailing Address - City:NUNICA
Mailing Address - State:MI
Mailing Address - Zip Code:49448-9406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 EMBASSY DR SE STE 400
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2416
Practice Address - Country:US
Practice Address - Phone:616-988-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5601011972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program