Provider Demographics
NPI:1902373095
Name:BOURCY-CRANDELL, ALEXANDRA L (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:L
Last Name:BOURCY-CRANDELL
Suffix:
Gender:F
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 1:29 FRIAR TUCK CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-3012
Mailing Address - Country:US
Mailing Address - Phone:585-698-0967
Mailing Address - Fax:
Practice Address - Street 1:1503 HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2113
Practice Address - Country:US
Practice Address - Phone:662-328-9623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-27
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA56628363A00000X, 207Q00000X, 363AM0700X
MSPA00673363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPA00673OtherMS MEDICAL BOARD
CAPA56628OtherSTATE OF CALIFORNIA DCA