Provider Demographics
NPI:1912472630
Name:CALLISON-BURCH, ALEXA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:CALLISON-BURCH
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 1:350 CLIFF ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3334
Mailing Address - Country:US
Mailing Address - Phone:307-438-3008
Mailing Address - Fax:
Practice Address - Street 1:14 GREAT PLAINS RD
Practice Address - Street 2:
Practice Address - City:ARAPAHOE
Practice Address - State:WY
Practice Address - Zip Code:82510
Practice Address - Country:US
Practice Address - Phone:307-856-9281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant