Basic Information
| Provider Information | |||||||||
| NPI: | 1386032647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALEXANDER | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | MILES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILES | ||||||||
| OtherFirstName: | LEAH | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 33369 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282333369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043648100 | ||||||||
| FaxNumber: | 7043652073 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 MATTHEWS TOWNSHIP PKWY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281052387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048411444 | ||||||||
| FaxNumber: | 7048492520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2015 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-05475 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1386032647 | 05 | NC | MEDICAID |