Provider Demographics
NPI:1770866402
Name:WACK, ALEXANDRA M (CRNP)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:M
Last Name:WACK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-2502
Mailing Address - Country:US
Mailing Address - Phone:610-525-6086
Mailing Address - Fax:610-525-6631
Practice Address - Street 1:918 COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-2502
Practice Address - Country:US
Practice Address - Phone:610-525-6086
Practice Address - Fax:610-525-6631
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011592363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner