Provider Demographics
NPI:1063066769
Name:SOARES, ALEXANDRIA (PTA)
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:SOARES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3912 BREEZEPORT WAY APT 201
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1094
Mailing Address - Country:US
Mailing Address - Phone:818-825-2074
Mailing Address - Fax:
Practice Address - Street 1:11015 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-3225
Practice Address - Country:US
Practice Address - Phone:757-591-7291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605333225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant