Provider Demographics
NPI:1659915486
Name:HAEMER, ALEXA RENEE (PA)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:RENEE
Last Name:HAEMER
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 1:500 PORTION RD STE 11
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4587
Mailing Address - Country:US
Mailing Address - Phone:631-648-0101
Mailing Address - Fax:
Practice Address - Street 1:500 PORTION RD STE 11
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4587
Practice Address - Country:US
Practice Address - Phone:631-484-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024379363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical