Basic Information
Provider Information | |||||||||
NPI: | 1144672361 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HYNDMAN | ||||||||
FirstName: | ALEXANDRA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEVRIES | ||||||||
OtherFirstName: | ALEXANDRA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
Address2: |   | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838146051 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086253800 | ||||||||
FaxNumber: | 2086253801 | ||||||||
Practice Location | |||||||||
Address1: | 2236 N MERRITT CREEK LOOP STE A | ||||||||
Address2: |   | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838144960 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086253800 | ||||||||
FaxNumber: | 2086253801 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2016 | ||||||||
LastUpdateDate: | 09/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA1916 | ID | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.