Provider Demographics
NPI:1720488729
Name:WALDRON, ALEXANDRA PAIGE (PTA)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:PAIGE
Last Name:WALDRON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 KELLEY ST, TRAVERSE CITY, MI 49686
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2466
Mailing Address - Country:US
Mailing Address - Phone:360-970-9812
Mailing Address - Fax:
Practice Address - Street 1:1000 PAVILIONS CIR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3098
Practice Address - Country:US
Practice Address - Phone:231-932-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004565225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant