Provider Demographics
NPI:1629092424
Name:ALEXANDER, LARRY D (PA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:ALEXANDER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 W ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8965
Mailing Address - Country:US
Mailing Address - Phone:231-935-0900
Mailing Address - Fax:231-935-0308
Practice Address - Street 1:1221 SIXTH ST STE 300
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2360
Practice Address - Country:US
Practice Address - Phone:231-935-2400
Practice Address - Fax:231-392-2424
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004425363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q28919Medicare UPIN
0M87900Medicare ID - Type Unspecified