Provider Demographics
NPI:1679050777
Name:WILSON, ALEXANDRIA LAUREN (PA)
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:LAUREN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:793 EASTERN BYP STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2425
Mailing Address - Country:US
Mailing Address - Phone:859-626-8645
Mailing Address - Fax:859-626-8661
Practice Address - Street 1:793 EASTERN BYP STE 101
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2425
Practice Address - Country:US
Practice Address - Phone:859-626-8645
Practice Address - Fax:859-626-8661
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2441363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant