Provider Demographics
NPI:1639898059
Name:KROTZ, ALIX NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:ALIX
Middle Name:NICOLE
Last Name:KROTZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ALIX
Other - Middle Name:NICOLE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:28480 RIPPLE BROOK LN
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92585-3329
Mailing Address - Country:US
Mailing Address - Phone:951-388-9021
Mailing Address - Fax:
Practice Address - Street 1:27300 IRIS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4802
Practice Address - Country:US
Practice Address - Phone:951-243-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA61799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program