Provider Demographics
NPI:1730890161
Name:WALL, ALEXANDRA GRACE
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:GRACE
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6164 CEDARBLUFF CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45233-4874
Mailing Address - Country:US
Mailing Address - Phone:513-373-0360
Mailing Address - Fax:
Practice Address - Street 1:6164 CEDARBLUFF CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45233-4874
Practice Address - Country:US
Practice Address - Phone:513-373-0360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant