Provider Demographics
NPI:1821745985
Name:ELLIS, ALEXANDRA K
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:K
Last Name:ELLIS
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 1:270 PLEASANT ST APT A134
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2470
Mailing Address - Country:US
Mailing Address - Phone:304-549-4244
Mailing Address - Fax:
Practice Address - Street 1:850 BOYLSTON ST STE 530
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2475
Practice Address - Country:US
Practice Address - Phone:617-732-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA8583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant