Provider Demographics
NPI:1700306453
Name:BRUNO, ALEXANDRA ST ANGELO (PA)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:ST ANGELO
Last Name:BRUNO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:LAUREN
Other - Last Name:ST. ANGELO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5000 HENNESSY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5000 HENNESSY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4375
Practice Address - Country:US
Practice Address - Phone:225-926-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA305960363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant