Provider Demographics
NPI:1255801551
Name:AUGUST, ALEXANDRA LOUISE (DPT)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:LOUISE
Last Name:AUGUST
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 BLOOMFIELD ST
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-3462
Mailing Address - Country:US
Mailing Address - Phone:315-430-6942
Mailing Address - Fax:
Practice Address - Street 1:600 S WILBUR AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-2730
Practice Address - Country:US
Practice Address - Phone:131-543-0694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043778225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1598806564Medicaid