Provider Demographics
NPI:1770002396
Name:WILSON, ALEXANDRA CATHERYN
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:CATHERYN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 W HORIZON RIDGE PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-4901
Mailing Address - Country:US
Mailing Address - Phone:702-489-9127
Mailing Address - Fax:702-489-9134
Practice Address - Street 1:11201 S EASTERN AVE STE 220
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-6202
Practice Address - Country:US
Practice Address - Phone:702-614-0324
Practice Address - Fax:702-614-0324
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1770002396Medicaid