Provider Demographics
NPI:1649815341
Name:KELLY, ALEXANDRA LEGGETT (PA-C)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:LEGGETT
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:ELIZABETH
Other - Last Name:LEGGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1700 POST OAK BLVD STE 11501160
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77056-3963
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:
Practice Address - Street 1:1700 POST OAK BLVD STE 11501160
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77056-3963
Practice Address - Country:US
Practice Address - Phone:888-663-6331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC07428363A00000X
TXPA12908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA12908OtherTEXAS MEDICAL BOARD
MDC0007428OtherMARYLAND DEPARTMENT OF HEALTH BOARD OF PHYSICIANS