Provider Demographics
NPI:1700319647
Name:SHIELDS, ALEXANDRA KATHERINE (PA)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:KATHERINE
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:KATHERINE
Other - Last Name:OLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1722 SHAFFER ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1633
Mailing Address - Country:US
Mailing Address - Phone:269-343-1555
Mailing Address - Fax:
Practice Address - Street 1:1722 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1633
Practice Address - Country:US
Practice Address - Phone:269-343-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008277363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant