Provider Demographics
NPI:1205259447
Name:HIROSE, ALEX (PA-C)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:HIROSE
Suffix:
Gender:M
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 1:8081 INNOVATION PARK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4867
Mailing Address - Country:US
Mailing Address - Phone:571-472-4724
Mailing Address - Fax:571-472-0241
Practice Address - Street 1:8081 INNOVATION PARK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4867
Practice Address - Country:US
Practice Address - Phone:571-472-4724
Practice Address - Fax:571-472-0241
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2021-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0003903363A00000X
COPA.0003903363AM0700X
VA0110008156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical