Provider Demographics
NPI:1689140485
Name:CONWAY, ALICIA ANNETTE (MPH, PA-C)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANNETTE
Last Name:CONWAY
Suffix:
Gender:F
Credentials:MPH, PA-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:ANNETTE
Other - Last Name:CONWAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:1700 N TULLY RD APT E148
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95380-6853
Mailing Address - Country:US
Mailing Address - Phone:916-601-4696
Mailing Address - Fax:
Practice Address - Street 1:420 W ACACIA ST STE 1
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2441
Practice Address - Country:US
Practice Address - Phone:209-948-1583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57581363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2210OtherTRICARE PRIME