Basic Information
| Provider Information | |||||||||
| NPI: | 1629370754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAUGHAN | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | ARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ARD | ||||||||
| OtherFirstName: | ALEXANDRA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10170 SORRENTO VALLEY RD | ||||||||
| Address2: | MAIL DROP SV-5 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587845888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10666 N TORREY PINES RD | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920371027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585544310 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2010 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA21317 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | EJ473Z | 01 | CA | MEDICARE PTAN | OTHER |