Basic Information
| Provider Information | |||||||||
| NPI: | 1073124590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALKUSH | ||||||||
| OtherFirstName: | ALEXANDRA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 203 S ROLLIE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LUPTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806211508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038926401 | ||||||||
| FaxNumber: | 3032864589 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 E EGBERT ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806012404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036972583 | ||||||||
| FaxNumber: | 3036554924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2020 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.0006314 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9000184561 | 05 | CO | MEDICAID |