Provider Demographics
NPI:1679386098
Name:DE LA ROSA PEREZ, ALEJANDRA (PA-C)
Entity type:Individual
Prefix:
First Name:ALEJANDRA
Middle Name:
Last Name:DE LA ROSA PEREZ
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16101 SW 102ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-3107
Mailing Address - Country:US
Mailing Address - Phone:786-322-9904
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:786-322-9904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-29
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085011152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant