Provider Demographics
NPI:1720553159
Name:DEBETENCOURT, ALEXANDRE ANDRE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDRE
Middle Name:ANDRE
Last Name:DEBETENCOURT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BESTGATE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3371
Mailing Address - Country:US
Mailing Address - Phone:410-266-2720
Mailing Address - Fax:410-224-0209
Practice Address - Street 1:1000 BESTGATE RD STE 400
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3371
Practice Address - Country:US
Practice Address - Phone:410-266-2720
Practice Address - Fax:410-224-0209
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06988363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD140207200Medicaid