Provider Demographics
NPI:1538824156
Name:CONWAY, ALEXANDRA (MS, LAT, ATC, EMT-B)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:CONWAY
Suffix:
Gender:F
Credentials:MS, LAT, ATC, EMT-B
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:
Other - Last Name:IAKIMENKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LAT, ATC, EMT-B
Mailing Address - Street 1:6204 AVENEL BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-3959
Mailing Address - Country:US
Mailing Address - Phone:484-716-0593
Mailing Address - Fax:
Practice Address - Street 1:1900 W OLNEY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-1108
Practice Address - Country:US
Practice Address - Phone:215-951-1519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0081922255A2300X
PA0912212146N00000X
PA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0912212OtherEMT