Provider Demographics
NPI:1104247741
Name:RUZICKA, ALEXANDRIA (PA-C)
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:RUZICKA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 ALBY STREET
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002
Mailing Address - Country:US
Mailing Address - Phone:618-474-8052
Mailing Address - Fax:
Practice Address - Street 1:4411 ALBY STREET
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002
Practice Address - Country:US
Practice Address - Phone:618-474-8052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-29
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004855363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant